OUTLINES 

OF 

PATHOLOGY 

AND 

PRACTICE OF MEDICINE. 



BY 

WILLIAM PULTENEY ALISON, 

M.D., F.R.S.E., ' 4^ 

FBLLOW AND LATE PRESIDENT OF THE ROYAL COLLEGE OF PHYSICIANS, EDINBURGH, AND 
OF THE MEDICO-CHIRURGICAL SOCIETY, EDINBURGH; HONORARY FELLOW OF THE KING'S 
AND QUEEN'S COLLEGE OF PHYSICIANS OP IRELAND, AND OF THE ROYAL MEDICAL 
SOCIETY, EDINBURGH; PROFESSOR OF THE PRACTICE OF SIEDICINE IN THE UNIVERSITY 
OF EDINBURGH, AND ONE OF THE PHYSICIANS IN ORDINARY TO HER MAJESTY FOR 
SCOTLAND. 



WILLIAM BLACKWOOD AND SONS, EDINBURGH, 
AND 22 PALL-MALL, LONDON. 
MDCCCXLIV. 



PRINTED BY iVEILL AND COMPANY, EDINBUEGH. 



PREFACE. 



In attempting to compress, within the limits of a 
Text-book for Lectures, the facts which seem to me best 
ascertained in regard to the nature, progress, and symp- 
toms of Diseases, and the effects of Remedies upon them, 
it has been my object to simplify, as far as possible, both 
the diagnostic marks of Diseases, and the practical rules 
for their treatment, — dwelling only upon those, an accu- 
rate knowledge of which may be acquired without much 
difficulty, and on which it has appeared to me, in prac- 
tice, that we can rely with most confidence. I have en- 
deavoured to connect these practical rules and direc- 
tions with as full a statement as the limits of such a 
work will permit, of the grounds of those opinions, in 
regard to the causes, the intimate nature, and fatal 
tendency of Diseases, which seem to me, in the present 
state of our knowledge, to be supported by the best evi- 
dence ; because notwithstanding all that has been said, 



VI 



PREFACE. 



and may be said, against Medical speculation, I am fully 
convinced of the truth of the observation of Dr Cullen, 
that " at all times the Practice of Medicine has been, 
and still is, with every person, founded more or less 
upon certain principles established by reasoning from 
which it evidently follows, that any one who undertakes 
to teach the Practice of Medicine must be prepared to 
explain the grounds of his opinions ; as well as to state 
the facts, and describe the appearances, on which he is 
to found his practical precepts. 

It may be thought by some of those who have at- 
tended closely to the recent progress of Microscopical 
and Chemical inquiries, into the structure and functions 
of living bodies, in health and disease, that I might have 
laid down more accurate and comprehensive principles 
in regard to the nature of various diseases, founded on 
those inquiries ; but any such principles would at this 
moment have been deficient in certainty and precision ; 
and I have therefore not thought myself justified in going- 
farther, than to point out the questions in Physiology 
and Pathology which especially demand the prosecution 
and completion of these inquiries ; — always, however, 
under this reservation, that the laws of Chemistry, as 
well as of Mechanics, are subject to a certain modifica- 
tion in all living bodies; — and to express in general terms 
my conviction, that these are the most important ques- 
tions which remain to be solved in those sciences. 

I should probably have thought it right to enter on 



PREFACE. 



vii 



more details in diflPerent parts of this work, and frequently 
to refer to tlie books in wHcli minute information re- 
garding individual diseases is to be found, had I not 
been anticipated by the fuller and elaborate works of Dr 
Copland, Dr Tweedie, and Dr Craigie, one or other 
of which is likely to be in the hands of almost every one 
who is now qualifying himself for the duties of the me- 
dical profession. 



CONTENTS. 



PART I. 

PAGE 

PRELIMINARY OBSERVATIONS, ... 1 



CHAPTER I. 

Of cases of sudden or violent death, ... 3 
CHAPTER II. 

Of DISEA.SES IN GENERAL, THEIR FATAL TERMINATIONS, OR 

SPONTANEOUS DECLINE, . . . 32 

CHAPTER III. 

Of THE REMOTE CAUSES OF DISEASES IN GENERAL, AND THE 

MEANS OF THEIR PREVENTION, . . 47 

CHAPTER IV. 

Of the ACTION OF REMEDIES IN GENERAL, AND THE EVI- 
DENCE OF THEIR EFFICACY, . . 74 



X 



CONTENTS. 



PART II. 

PAGE 

OF FEBRILE DISEASES, 92 

DIVISION I. 

OF INFLAMMATORY DISEASES, 94 

CHAPTER I. 

Of inflammation in general, .... 95 
Sect. I. Of the Primary and Characteristic Pheno- 
mena of Inflammation, . . 93 
Sect. II. Of the Present State of our Knowledge of 

the Essential Nature of Inflammation, 108 
Sect. III. Of the Remote Causes of Inflammation, 140 

Sect. IV. Of the Local Effects, and Anatomical Cha- 
racters of Inflammation, . . . 145 

Sect. V. Of the Symptoms resulting from these 

Effects of Inflammation, . . 163 

Sect. VI. Of the Varieties of Inflammation, . 173 

Sect. VII. Of the Fatal Terminations of Inflamma- 
tion, 212 

Sect. VIII. Of the Treatment of Inflammation, 213 
CHAPTER II. 

Of inflammation of the air- passages and lungs, . 251 

Sect. I. Of Cynanche Tonsillaris, . . . 251 

Sect. II. Of Cynanche Laryngea, and Trachealis, 257 

Sect. III. Of Bronchitis, .... 262 

Sect. IV. Of Peripneumony, .... 275 

Sect. V. Of Phthisis Pulmonalis, . . . 284 

Sect. VI. Of Pleurisy, Acute and Chronic, . • 290 



CONTENTS. 



XI 



CHAPTER III. 

PAGE 

Of inflammations of the heart and bloodvessels, 295 

CHAPTER IV. 
Of inflammations of the viscera of the abdomen and 

PELVIS, .... 307 
Sect. I. Of Hepatitis, . . . . 307 
Sect. II. Of Peritonitis, .... 313 
Sect. III. Of Inflammation of the Mucous Mem- 
brane of the Stomach and Intestines, 321 
Sect. IV. Of Inflammation of the Kidneys, and other 

Urinary Organs, . . . 328 
Sect. V. Of Inflammation of the Uterus, . 324 

CHAPTER V. 
Of inflammations of the nervous system and organs of 

SENSE, .... 337 

Sect. I. Of Inflammation of the Brain, . . 337 

Sect. II. Of Inflammation of the Spinal Cord, 348 

Sect. III. Of Inflammation of the Eye, t . 352 

Sect. IV. Of Inflammation of the Ear, . . 356 

CHAPTER VI. 
Of inflammations of the organs of locomotion and 

SUPPORT, .... 359 
Sect. I. Of Rheumatism, . . . . 359 

Sect. 11. Of Gout 366 

Sect. III. Of Inflammation of the Periosteum, Bones, 

and Joints, . . . . 369 



CHAPTER VII. 
Of inflammations of the integuments, 



377 



xii 



CONTENTS. 



DIVISION 11. 

PAGE 

OF FEVERS PROPERLY SO CALLED, . . . . 389 

CHAPTEE I. 

Of idiopathic fevers, ...... 389 

Sect. I. Of the Diagnostic Symptoms and Varieties 

of Idiopathic Fever, . . 391 

Sect. II. Of the Appearances on Dissection after 

Idiopathic Fevers, . . . 406 

Sect. III. Of the Remote Causes of Idiopathic Fevers, 417 

Sect. IV. Of the Pathology of Idiopathic Fevers, 

and of their Fatal Terminations, 430 

Sect. V. Of the Treatment of Idiopathic Fevers, 448 

CHAPTER II. 

Of the eruptive fevers, or contagious exanthemata, 467 
Sect. I. Of the Smallpox, .... 471 
Sect. II. Of the Measles, .... 477 
Sect. III. Of the Scarlatina and Malignant Sore- 
Throat, 481 

Sect. IV. Of the Erysipelas, . . . . 490 

y' Sect. V. Of the Plague, . . . • 495 

PAET III. 

OF CHRONIC OR NON-FEBRILE DISEASES, . 501 
CHAPTER I. 

Of chronic or non-febrile diseases in general, . . 501 
Sect. I. General View of the Modes of Diseased 
Action observed in Diseases of this 
class, ...... 502 



CONTENTS. 



Xlll 



Sect. II. General View of the Kinds of Morbid 
Structure observed in Diseases of this 
class, . • • 

Sect. III. General View of the Causes and History 
of these Chronic Diseases, and of the 
Objects of Practice in regard to them, 520 

CHAPTER II. 

Of chronic diseases of the air-passages and lungs, 529 



CHAPTER III. 

Of chronic diseases of the heart and bloodvessels, 533 
Sect. I. Of Chronic Diseases of the Heart, . 533 
Syncope, ^ 

Palpitation, ^ Functional and Organic. 

Angina Pectoris, ) 

Cyanosis, 

Sect. II. Of Chronic Diseases of the Arteries, . 551 
Aneurism. 

Spontaneous Gangrene. 
Sect. III. Of Chronic Diseases of the Circulation in, 
and Exhalations from, the Capillary 

Vessels, 559 

Congestions of Blood. 
Hsemorrhages. 
Dropsical Effusions. 

CHAPTER IV. 

Of chronic diseases of the organs of digestion and 

assimilation. . . . . . . 579 

Sect. I. Preliminary Observations, . . 579 
Sect. II. Of Chronic Diseases of the Stomach, 586 
Sect. III. Of Chronic Diseases of the Liver, Pan- 
creas, and Spleen, . . 598 



XIV 



CONTENTS. 



PAGE 

Cholera. 

Jaundice. 

Granular Degeneration, and other Or- 
ganic Diseases. 
Of Chronic Diseases of the Intestines, 611 
Diarrhoea. 
Colic. 

Tubercular and other Organic Diseases. 
Worms. 
Ascites. 

Epidemic Cholera. 
Of Chronic Diseases of the Function of 

Assimilation, . . . 633 
Scurvy. 

Dry Gangrene. 
Kickets, 
Diabetes. 
Lithiasis. 

CHAPTER V. 

Of chronic diseases of the organs of urine and gene- 
ration, . . . 653 
Sect. I. Of Chronic Diseases of the Kidneys, 653 
Sect. II. Of Chronic Diseases of the Bladder, 658 
Sect. III. Of Chronic Diseases of the Male Organs 

of Generation, . . . 659 

Sect. IV. Of Chronic Diseases of the Uterus and 

Ovaria, .... 662 
Amenorrhoea. 
Menorrhagia. 
Leucorrhoea. 
Organic Diseases. 



Sect. IV. 



Sect. V. 



CONTENTS. 



XV 



CHAPTER VI. 

PAGE 

Of chronic diseases of the nervous system and organs 

OF sense, . . . 676 

Sect. I. Preliminary Observations, . . 676 

Sect. II. Of Apoplexy and Palsy, . . 687 

Sect. III. Of Spasmodic Diseases, . . 698 

Convulsions and Epilepsy. 

Chorea. 

Hysteria and Analogous Spasms. 

Tetanus. 

Hydrophobia. 

Sect. IV. Of Disordered Sensations, . . 716 

Amaurosis. 

Anaesthesia. 

Neuralgia. 

Spectral Illusions. 
Sect. V. Of Mental Disorders, . . . 721 

Amentia. 

Somnambulism. 

Dementia. 



OUTLINES 
PRACTICE 



or PATHOLOGY 

AND 

OF MEDICINE. 



PART L 

PRELIMINAHY OBSEEVATIONS. 

As the object of Physiology is to deliver the history 
and explanation of all the phenomena by which the liv- 
ing body is distinguished from the dead, so the object of 
Pathology is to describe and explain all the phenomena 
by which the diseased states of the living body differ 
from the healthy ; and we call all states of the living 
body diseased, in which there are such deviations from 
its natural condition as cause suffering or inconvenience, 
or endanger life. 

A slight attention to this subject is sufficient to shew, 
that there are many facts in regard to the operation of 
external causes on the human body, and the modes of 
diseased action assumed by its different organs, which 
could not possibly have been inferred from our know- 
ledge of the structure and healthy action of parts, which 

1 - 



2 



PEELIMINARY OBSERVATIONS. 



are made known to us only by observation of the dis- 
eased conditions of tbe body themselves, and can only 
be properly generalized by an induction strictly confined 
to this department of knowledge. 

The fewer and more comprehensive these ultimate 
facts or laws in this department of nature, the more 
successful must the induction be regarded ; and some of 
them have been already so far ascertained, as to enable 
us to treat the subject in some measure synthetically. 

The simplest exemplification of these ultimate facts 
in Pathology is to be found in cases of sudden death, and 
in the action of violent injuries, and we, therefore, pre- 
mise a short account of difierent fatal injuries, to dis- 
cussions on the pathology of the difi'erent diseases. 



CHAPTER I. 



OF CASES OF SUDDEN OR VIOLENT DEATH. 

The operation of all causes of sudden or violent death 
may be referred ultimately to two modes of injury, which 
are in some cases perfectly distinct, although in others 
they are evidently blended. We cannot, indeed, arrange 
the causes of violent death strictly according to these dif- 
ferences in the mode of their action, because the same 
causes appear to act, under different circumstances, 
sometimes chiefly in the one way, and at other times in 
the other ; but we can point out that their fatal effects 
are always produced, either by their directly depresdng 
or suspending the vital action of the organs of circulation^ 
— or else, by their obstructing the arterialization of the 
bloody and therefore, according to principles known in 
Physiology, arresting the circulation at the lungs. 

We know farther, that the first effect, or what may be 
called in general death by Syncope^ or beginning at the 
Heart, may be produced in two ways : 1 . By a cause 
acting on the system, as a concussion or shock, depress- 
ing the vital powers by which the blood is moved ; 2. 
By abstraction, sudden or gradual, of the vital stimulus ; 
— and that the second effect may be produced also in 
two ways, 1. By injury of the Nervous System, arrest- 
ing respiration by causing insensibility, i. e. producing 
death by Coma^ or beginning at the Brain ; and, 2. By 



4 



OUTLINES OF PATHOLOGY AND PRACTICE. 



direct impediment to tlie access of air to the lungs, pro- 
ducing what is strictly called death by Asphyxia^ or. 
beginning at the Lungs. 

To these principles we can ascribe the known effects 
of the following kinds of injury; and having illustrated 
these, we may afterwards refer to them with advantagCy 
as the facts most analogous to the changes that consti- 
tute disease, and especially to those circumstances of 
disease which are immediately dangerous to life. 

I. It is to be expected, from what we know of the 
functions of the Nervous System^ that Injuries affecting 
it should impair, more or less completely, the sensations, 
the mental powers, and the voluntary motions ; but they 
become dangerous to life only in the ways already spe- 
cified, inasmuch as they affect the fundamental function 
of Circulation, either directly, or through the interven- 
tion of the Respiration. 

1. The most violent injuries, affecting the Nervous 
System, suddenly arrest, or greatly impair, the motion 
of the blood in all parts of the body, i, e. they produce a 
state of Syncope or faintness ; the heart's action either 
suddenly ceasing, or becoming very feeble ; the pulse 
small, or imperceptible, and the surface cold, often damp ; 
at the same time that sensation and voluntary motion 
are suspended. This direct effect on the circulation of 
violent injuries of the brain was overlooked by Bichat, 
but is well illustrated by Dr Wilson Philip ; and has 
long been known to practical men, as constituting the 
most characteristic part of the first symptoms of general 
Concussion of the braiii, as distinguished from more par- 
tial Compression of it. 

The experiments of Legallois and Dr Wilson 



OF CASES OF SUDDEN DEATH. 



5 



Philip fartlier sliew, that this effect on the heart's ac- 
tions, and on the motion of the blood in the capillaries, 
may result from injury of any part of the hrain or spinal 
cord, if it extend to large portions of the nervous matter ; 
and many examples inform us, that when concussion is 
general over the whole system, it is frequently fatal, in 
this way, without any visible disorganization being pro- 
duced. 

After death from affection of the nervous system, thus 
directly influencing circulation, the heart is sometimes 
found, especially in the most sudden cases, quite empty 
of blood (the cause of which appearance is doubtful) ; in 
other cases distended, but with no decided difference as 
to the quantity of blood in its right and left sides. 

In cases of this kind, it is not quite certain that the 
fatal depression of the vis vita3 in the circulating system 
is the effect of an impression made on the nervous 
system; and some have supposed, that such injuries 
are fatal by a direct effect on the circulation in the smal- 
ler arteries, checking it so completely, as to throw a bur- 
den on the heart which it is unable to overcome. But 
the effects of violent injuries confined to the brain or 
spinal cord, as in the experiments of Wilson Philip 
and Legallois, are just similar to those of a general 
concussion ; mental causes, of powerful operation, which 
certainly act through the nervous system, have the 
same effect ; partial although violent injury of other tex- 
tures has no such effect ; nor does such an effect result 
from suddenly stopping the flow of blood in large arte- 
ries by ligatures, or by amputation of a large limb ; and 
therefore it is highly probable, that general concussion 
of the body does act^ as is generally thought, on the vas- 
cular system through the intervention of the nervous > 



6 OUTLINES OF PATHOLOGY AND PRACTICE, 



and tliis is one of the facts included under the general 
principle in Physiology, that the nervous system, al- 
though not necessarily concerned in the functions of or- 
ganic life, is yet so connected with them, that, by certain 
changes in it, any of these functions may be variously 
altered, or even totally suspended. 

There is great variety as to the amount of injury which 
will produce, in different individuals of the human spe- 
cies, the sedative effect on the circulation now in ques- 
tion ; and as to the duration and termination of that se- 
dative effect, which sometimes abates quickly, and some- 
times gradually increases till it is fatal, some hours after 
the injury. 

There appears to be a variety also in the part of the 
circulation chiefly affected by such injuries. In some in- 
stances the circulation on the surface appears peculiarly 
affected, and the heat of the surface is reduced much more 
than in others, where the hearths action is equally depress- 
ed. In experiments by Chossat, the heart's action was for 
some time little affected by certain injuries of the brain, 
which checked the circulation in the capillaries so com- 
pletely, as to suspend the secretions and the evolution of 
heat. When the spinal cord has been severely injured 
in the human body, below the neck, the circulation in 
the capillaries has generally appeared, for some time, 
more affected than the heart's action, although it is by 
gradual failure of the circulation that such cases are ul- 
timately fatal. 

There is also great variety in the alterations of the 
functions of the Nervous System itself, which result 
from such injuries, and accompany or succeed the seda- 
tive effect on the circulation. In some cases the coma 
is long continued and profound, in others slight and 



OF CASES OF SUDDEN DEATH. 



7 



transient ; in some cases it is attended by much convul- 
sion, in others by little or none ; in some cases it is suc- 
ceeded by much headach, or by general or partial amentia 
or delirium, or by incessant nausea and vomiting ; and 
in others by none of these. And it is certain that all 
these varieties in the symptoms, in such cases, may be 
independent of any perceptible alteration of the structure 
of the nervous system.* 

This primary effect on the circulation, of extensive 
injury of the Nervous System, is seldom the immediate 
object of practice, because if not immediately fatal, it is 
usually followed by symptoms of inflammation, against 
which the chief remedies must be directed ; but in few 
cases, the danger from the first effect of the concussion 
may be properly averted by internal and external sti- 
muli, cautiously used. 

It is an important observation, that when injuries that 
have affected the Nervous System, and through it the 
circulation, in the manner now stated, are not quickly 
fatal, but are followed by the slower processes, to be af- 
terwards described, of inflammation and fever, the pro- 
gress of these is frequently modified by the preceding or 
accompanying state of the system, likewise consequent 
on the injuries ; and that in these circumstances fever 
is apt to assume the form to be afterwards described as 
typhoid^ and inflammation to terminate rapidly in gan- 
grene, f How far these facts should be relied on, as 
indicating the true pathology of Typhoid Fever, is still 
doubtful ; but it is certain that, in these circumstances, the 
practice afterwards to be considered as suited to typhoid 
fever is admissible, and sometimes decidedly beneficial. 

* See Brodie, Medico- Chirurgical Transactions, vol. xiv. 
t See particularly Travers on Constitutional Irritation. 



8 OUTLINES OF PATHOLOGY AND PRACTICE. 



2. A slighter, and especially a more partial injury of 
the Brain, or upper part of the Spinal Cord, if its action 
be of sufficient intensity and duration, often produces 
death in a totally different way, viz. by Coma or stupor, 
■ — " superstite actione cordis et arteriarum." The es- 
sential peculiarity of this kind of fatal effect of an injury 
of the Nervous System is, that Respiration takes place 
imperfectly, and ultimately is suspended, probably by 
reason of the defect of sensation ; and in the cases which 
are characteristic examples of this mode of death, the 
Circulation, and sometimes the animal heat, not only 
continue entire up to the moment when the last breath 
is drawn, but even survive the respiration for a short 
time ; during which time, of course, venous blood moves 
along the arteries; but the venous blood, according to 
the general law established in the Physiology of Respira- 
tion, soon ceases to make its way through" the capillaries 
of the lungs, and the circulation is therefore soon brought 
to a stand. 

The experiments of many physiologists shew, that it 
is in this way only that death is produced when the 
spinal cord is cut in the upper part of the neck, or the 
head cut off, without violent haemorrhage, and without 
any large portion of the brain or spinal cord being crushed. 

The most common injuries of the Nervous System which 
cause death, thus preceded by Coma, are those in which 
there is partial compression of the nervous matter, as by 
depressed bone, or effused blood, pus, or serum ; but it 
is in the same way that death is often produced by dis- 
organizations of the brain, which do not necessarily im- 
ply compression of its substance ; and also by certain 
poisons, the effect of which on its functions does not ap- 
pear to depend on alteration of the pressure on it ; and 



OF CASES OF SUDDEN DEATH. 



9 



it is therefore incorrect to speak generally of sucli symp- 
toms as indications of pressure on the brain. 

We know from Physiology, that the part of the Ner- 
vous System which must be specially affected in these 
cases, where the failure of respiration is the immediate 
cause of death, must be at the sides of the medulla ob- 
longata ; but the part visibly injured is often conside- 
rably distant from this. 

There is very great variety as to the duration and 
degree of the insensibility, vfhich precedes the failure of 
respiration in such cases of injury of the Nervous Sys- 
tem ; and as to the other affections, either of the brain 
and nerves, or of other organs, which may precede or 
attend that insensibility, such as Jieadach, delirium, som- 
nolency, spasms, palsy, dilated or contracted pupil, pre- 
ternaturally slov/, or frequent, or irregular pulse, &c. 
Even the function of respiration itself is variously af- 
fected in different cases of the kind, being sometimes 
hurried and imperfect, and in other cases unnaturally 
slow and deep, for some time before it is finally sup- 
pressed. After the death thus produced by injuries of 
the Nervous System, just as after death by asphyxia, 
we find, as might be expected, the blood accumulated 
chiefly in the lungs, pulmonary artery, right side of the 
heart, and great veins. 

The state of Coma, succeeding to injuries of the Ner- 
vous System, with or without those accompaniments, is 
often successfully treated by depleting remedies, and 
strictly antiphlogistic regimen, when depending on in- 
creased determination of blood to the brain and its mem- 
branes, or on inflammation there ; and, in a few cases, 
by surgical operation, when it can be ascertained to de- 
pend on mechanical compression. 



10 OUTLINES OF PATHOLOGY AND PRACTICE. 

These two modes in which injuries of the Nervous 
System may cause death, though perfectly distinct in 
some cases, are evidently combined in others ; the same 
cause both instantly weakening the circulation and like- 
w^ise deadening the sensibility, so as gradually to sup- 
press the respiration. And there are many cases of in- 
jury of the head, where insensibility and faintness from 
the concussion immediately succeed the accident, but 
quickly abate, and are succeeded after an interval by 
insensibility with full pulse, and death in the way of 
coma ; which may then be confidently ascribed to com- 
pression of the brain by effused blood or serum. 

There are various causes, physical and mental, w^hich 
affect the Nervous System, nearly in the manner of a 
Concussion, and are apt to produce a similar depressing, 
and sometimes dangerous, effect on the circulation, and 
the operation of which is illustrated by the facts now 
stated, as to the effects of mechanical injuries. They 
usually cause vertigo, tinnitus aurium, confusion of 
thought, and then often an instantaneous loss of sense^ 
intellect, and voluntary power, constituting what is called 
a complete fit of Syncope. One of these is, a sudden 
minution of the pressure, to which the brain and spinal 
cord had been previously subjected. Thus, when a de- 
pressed piece of bone, or a coagulum of blood, or a 
quantity of serum, which had long rested on a portion 
of the brain, has been removed, insensibility, and along 
with it sudden feebleness of circulation, have often en- 
sued. AYhen a large bloodvessel has given way in the 
head, and poured blood into the ventricles (implying, in 
the first instance, a sudden diminution of the pressure 
on a part of the nervous matter), a similar result has 
often been observed ; and been followed by a partial re- 



OF CASES OF SUDDEN DEATH. 



11 



covery of sense, and of pulse, and tlien by gradual acces- 
sion of fatal coma, as tlie effused blood has increased in 
quantity, and compressed the brain around it.* The 
sudden attack of insensibility, and sudden depression of 
the heart's action, which may often be determined by 
the erect posture during bloodletting, or by rapidly re- 
movino' the fluid of ascites without substitutino' artificial 
compression, must likewise be ascribed to sudden dimi- 
nution of the pressure on the brain, acting like a con- 
cussion ; and is illustrated by the attacks of syncope, 
with suspension, or great diminution, of the motion of 
the heart, which are often produced by rising suddenly 
after long stooping. 

The secondary action, or reaction on the heart, of sud- 
denly diminished pressure on the brain (even of such 
diminished pressure as results from previously weakened 
action of the heart itself), is illustrated by the well-known 
effect of the erect posture as a cause, and of the horizon- 
tal position as a remedy for Syncope, — not only for the 
affection of the Nervous System, but for the enfeebled 
action of the heart ; — and illustrates in its turn the in- 
fluence of all those causes of syncope which act primarily 
on the nervous system. 

One of these causes, which many persons have thought 
adequate to produce such an effect on the Nervous Sys- 
tem as shall act as a concussion, is the impression made 
by a cannon ball, or other large substance passing with 
immense velocity close to the head. 

A cause certainly adequate to produce fatal depres- 
sion of the heart's action, and which no doubt acts 
through the Nervous System in like manner as a con- 

* See Abercrombie on Diseases of Brain and Spinal Cord, p. 
228. et seq. 



12 OUTLINES OF PATHOLOGY AND PRACTICE. 



cussion of the brain, is a violent blow on the abdomen, 
especially on the epigastrium, which has been supposed 
to act immediately on the great semilunar ganglion. A 
draught of cold water taken when the body is heated and 
exhausted by fatigue, has in some cases been instanta- 
neously fatal in the same manner ; and the concussion 
from a violent and extensive wound of any part of the 
abdomen is usually fatal in the same rapid way, indepen- 
dently of haemorrhage, and before there is time for in- 
flammation to be established. These facts are important, 
as illustrating the more gradual, but very dangerous de- 
pression of the power of the heart, which is seen even 
in the earlier stages of inflammation, and other acute 
diseases, of the abdominal viscera. 

Violent injuries of various other parts of the body, 
especially if inflicted on a person of weakly habit, and 
in whom the nervous system is in a state of unnatural 
excitability (as from the habitual use of opium or spirits), 
may equally act on the footing of a concussion ; either 
causing sudden death, or so depressing the actions of the 
vascular system, as to give the typhoid form to the fever, 
and the gangrenous tendency to the inflammation, which 
are to result. This has been observed from severe sur- 
gical operations, and from extensive lacerated wounds, 
and bad compound fractures of various parts, even al- 
though there had been no general concussion of the body, 
nor insensibility immediately after the injury.* 

In the cases last mentioned, it can hardly be doubted 
that the violence, or peculiar nature of the Sensation, 
which attends the injury, is the intervening link through 
which the vital action of the heart is sympathetically 

* See Travers on Constitutional Irritation. 



OF CASES OF SUDDEN DEATH. 



13 



affected ; and accordingly, we have many facts to prove, 
that various violent or overpowering Sensations, intense 
Pain, or the sudden transition from pain to ease, and 
likevfise certain mental Emotions or Passions, as Joy, 
Grief, Anger, Fear, when acting in the utmost intensity, 
affect the circulating system just as a concussion does, 
and sometimes with fatal effect, — especially when they 
take place in persons in a state of unusual weakness or 
exhaustion. 

These facts do not establish, as Cullen and others 
supposed, a necessary dependence of the heart's action 
on the Brain, — a supposition which is inconsistent with 
facts now known in Physiology. They only concur with 
other facts in proving, that the heart's action is subject 
to an influence or control, from certain changes in the 
Nervous System, probably especially from changes which 
extend over the whole of that system, and which act at 
a peculiar advantage on the heart, as an organ connected, 
by the ganglionic nerves, with all parts of the cerebro- 
spinal axis.* 

Many of the stimulating remedies which are useful in 
Syncope, or in diseases threatening to end in fatal syn- 
cope, act obviously through the Nervous System on the 
heart. But two of the most active of these remedies, 
the affusion of cold water on the face and neck, and the 
application of stimuli to the nostrils, seem to have a pe- 
culiar mode of action, viz, exciting the act of Respiration, 
and thereby determining to the heart a larger quantity 
of its appropriate stimulus, arterial blood. 

IT. The effect of very intense Heat^ applied to a 
pretty large surface of the body, as in an extensive burn, 



* See Outlines of Physiology, p. 275. 



14 



OUTLINES OF PATHOLOGY AND PRACTICE. 



or to the whole body, as in the case of a coup de soleil, 
is also quite similar to that of concussion ; there is often 
insensibility, and always, when the case threatens the 
most immediate danger, there is the characteristic de- 
pression of the heart's action ; and when recoveries 
take place from the state of collapse (as it has been cal- 
led) immediately succeeding such injury in its extreme 
deoTee, it is often under the use of stimulatino- reme- 
dies.* 

But intense heat of the sun, in other circumstances,- — 
especially, as it would seem, if acting more gradually on 
a stronger habit of body, and when there has been less ex- 
haustion by muscular exercise, — has often produced a state 
of insensibility, in which the pulse has been fuller than 
natural, and the vessels of the head unnaturally turgid, 
and which has either been fatal in the way of coma, as 
above explained, or been relieved by copious evacuations, 
and cold ajDplications ; and the same cause has often 
produced other diseased conditions connected with a 
derangement of the action of vessels of the head.-j- In 
this case, the most injurious effect of the heat is evi- 
dently on the vascular system, exciting the action of the 
heart, and probably expanding the blood in the vessels ; 
and the brain suffers probably from increased compres- 
sion by the blood; whereas in the former case, the first 
and chief effect of the heat appears to be on the ner- 
vous system, and the heart suffers from the violent im- 
pression made there. 

* See T RAVERS, 1. c 

t See Mitchell in Edinburgh Medical and Surgical Journal, 
1828. 



OF CASES OF SUDDEN DEATH. 



15 



III. It appears from experiments on animals, by 
Font AN A, Huntee, and Buodie, and also from cases 
observed in tbe human body,* that the effect of Light- 
ning or Electricity, when acting with the utmost inten- 
sity, is likewise similar to concussion, depressing or even 
extinguishing the vital action in the vascular system, at 
the same time that it causes insensibility ; but that 
when acting in a less intense degree, it produces insen- 
sibility without any such immediate sedative effect on 
the circulation, — that this appears often to be connected 
with turgescence of the vessels of the head, and proba- 
bly expansion of their contents ; — and that it may termi- 
nate in death by coma, or be followed by partial and 
more permanent injury of some of the functions of the 
brain and nerves, — or may be effectually relieved by de- 
pleting remedies. 

IV. The effects of Cold on the body are remarkably 
various, according to circumstances, which demand at- 
tention. They depend, not so much on the degree of 
cold that is applied to the body, nor even on the degree 
to which the body is actually cooled, — as on the rapidity 
of the change, and probably on the intensity of the Sen- 
sation thus excited. Thus it was found by Chossat, 
that the temperature to which the bodies of animals 
killed by cold had been reduced before they died, was 
considerably various, and always higher, as the reduc- 
tion of temperature had been more rapid, and therefore 
more injurious. And the degree of effect of any cold 

* See, e, g. Parkinso?^, in Memoirs of Medical Society in Lon- 
don, vol. ii. ; and Macaulay, in Edinburgh Medico- Chirurgical 
Transactions, vol. ii. 



16 OUTLINES OF PATHOLOGY AND PRACTICE 



applied to tlie living body has always been observed to 
be greater, as tlie sensation it excites is tbe more intense 
and the more lasting ; and therefore to be increased by 
all circumstances, either of the body which undergoes 
the exposure, or of the degree and mode of the applica- 
tion of the cold, by which the intensity and duration of 
the sensation are increased. 

When cold is applied in such circumstances as to take 
full effect on the body, it has been commonly stated that 
it becomes dangerous by inducing stupor, and ultimately 
death in the way of coma. This effect of cold has certainly 
often been observed, and has sometimes been preceded by 
delirium, has sometimes been attended by haemorrhage 
from the nostrils or ears, and has been found on dissec- 
tion, connected with considerable serous effusion in the 
head. It is therefore probably in a great measure de- 
pendent on the greatly diminished flow of blood to the 
surface and extremities, and proportionally increased 
flow to the brain. Persons recovering, by assiduous ap- 
plication of heat, from this state of stupor, produced by 
cold, have continued comatose for hours after the cir- 
culation in their extremities has been well restored.*' 

But in those who become comatose from cold, the 
heart's action is at the same time enfeebled ; and it ap- 
pears distinctly, from experiments on animals, and ob- 
servations on the human body, that the most intense 
cold may be fatal in the same way as a concussion, by 
a direct depressing effect on the circulation ; in which 
case, of course, respiration continues up to the moment 
when the heart's action ceases, — the heart is found mo- 
tionless, and with arterial blood in its left cavities im- 

* See c. g. Kellie, in Ediiiburgh Medical Journal, vol. i. p. 304, 



OF CASES OF SUDDEN DEATH> 



IT 



mediately after death, — and the artificial respiration is 
quite ineffectual in prolonging life*. 

In all cases, cold acts as a sedative power on the ca- 
pillary circulation on the surface f, and Dr Edwards 
found that its repeated or long continued application 
has a peculiar effect in depressing the power of subse- 
quently generating heat. In some instances of frost- 
bite this effect is so powerful on the parts to which it is 
chiefly applied, as to put a final stop to all vital action 
in them, even when the system at large does not mate- 
rially suffer ; and in many cases, the sedative effect on 
the vital actions of frost-bitten parts is such, that the 
inflammation (which is excited in a greater or less 
degree by the return of heat to such limbs) shews evi- 
dent marks of deficient reaction, and tends rapidly to 
gangrene. 

But such effects of intense cold on the vital actions 
of individual parts ^ must be carefully distinguished from 
the case of cold acting as a powerful sedative on the 
whole system ; because in the first of these cases, when 
the general circulation is strong, the chief danger is 
from the inflammation, which is the direct consequence 
of the restoration of the circulation and natural heat of 
the part ; and this is chiefly to be moderated by causing 
that restoration to take place very gradually, therefore 
chiefly by cold applications tending to retard it ; whereas 
when the vital power of the whole system has been de- 
pressed, there is no such risk of local injury from the 

* See Chossat, Mem. sur T influence du Systeme nerveux sur la 
Chaleur Animale, p. 8. 

f Beaupre' on the Effects of Cold, translated by CLENDiNNiNGf, 
p. 131. 

B 



18 OUTLINES OF PATHOLOGY AND PRACTICE. 



restoration of temperature, and external heat and other 
stimuh may be much more freely applied. 

V. In regard to the action of Poisons on the animal 
economy, there are several questions of much import- 
ance, to which it is the more necessary to advert, as these 
phenomena are more analogous to the changes which 
take place in some of the most malignant diseases, than 
any others to which we can refer for illustration of those 
diseases, 

1. It has been long a subject of inquiry, whether it is 
essential to the action of poisons, that they should be 
absorbed into the circulation, and carried with the blood 
over different parts of the system ; or whether their action 
may be on the nerves of the parts to which they are 
directly applied, and the affection of the organs more 
necessary to life be produced sympathetically. 

That the peculiar agency, and even the fatal effect of 
some poisons, may be produced in this last way, appears 
distinctly, — 

a. From the very great rapidity of the action, e. g. of 
the oil of bitter almonds, and still more, of the hydro- 
cyanic acid, the application of which to the tongue of an 
animal, has been followed by death within eight, five, or 
even three seconds ; certainly before it can have reached 
the heart in the way of absorption and transmission 
along the vessels, on which organ its fatal effect, in such 
cases, is nevertheless mainly exerted. 

b. From the suddenly fatal effect of concentrated acids 
and alkalies taken into the stomach, which disorganize 
the mucous membrane there so completely that they can- 
not be absorbed from it ; but when in that concentrated 



OF CASES OF SUDDEN DEATH. 



19 



state produce death much more rapidly than they do, 
when so far diluted that their absorption is easy.* 

c. From the effect of many poisons, such as Opium, 
Belladonna, Aconite, Hydrocyanic Acid, having often 
been observed to take place, chiefly in parts in the neigh- 
bourhood of that to which they are applied, and not 
merely in the course of the blood passing thence to the 
heart. 

d. Perhaps also, from the effect of a poison lodged in . 
the stomach, having often been observed very rapidly to 
abate, as soon as it was discharged by vomiting. 

But there is abundant evidence, that in a great ma- 
jority of cases of poisoning, the effect produced is subse- 
quent to the absorption of the poison into the blood, and 
to its transport, in the blood, from the point where it is 
applied, to other parts of the system. 

The numerous experiments of F on tana, Moneo, 
Beodie, Magendie, Fodeea, Cheistison, Coindet, 
and Baeey, leave no room for doubt, that poisons in- 
serted into wounds, or laid in contact with internal mem- 
branes, are quickly absorbed into the blood ; that the 
passage of the venous blood, from that point towards the 
heart, is in most cases the only condition essential to 
their action ; and that such a diminution of atmospheric 
pressure on the surface where they are placed, as shall 
prevent their absorption, will also prevent, or even sus- 
pend, their action. 

But it is not so clear, to what distance from the point 
of its application a poison must be transported by the 
blood, in order to produce its full effect. The experi- 
ments of Dr Addison and Mr Moegan have shewn, 

* Christison on Poisons, p. 6.. 



20 



OUTLINES OF PATHOLOGY AND PRACTICE. 



that a poison introduced into a large vein will act, not- 
withstanding that its direct access to the heart is ob- 
structed, — that a poison introduced into the femoral 
artery will act as rapidly as one introduced into the jugu- 
lar vein, or carotid artery ; — and again, that when the 
blood from the carotid artery of one dog is sent to the 
brain of another, a poison may be applied to a wound in 
the first dog, and take full effect on him, without affect- 
ing the second. But these results do not seem sufficient 
to authorize the conclusion which they have been thought 
to support, — that the sole direct action of poisons is on 
the nerves of the vessels, and their action on the brain 
or heart only sympathetic* It still appears much more 
probable, that the greater part of the effect of poisons, 
which have been absorbed into the blood, is consequent 
on their direct application to the more important vital 
organs. 

Some poisons taken into the blood have been detected 
there, and the action of some has been observed to be at- 
tended by a change of the sensible qualities of the blood ; 
and especially by a diminution or loss of its coagulating 
property ; but many act fully without altering its sensible 
qualities ; when these are altered, it is doubtful how far 
the alteration is connected with the action of the poisons 
on the living solids ; and the loss of coagulating power 
is so often seen in cases of sudden death, that of itself it 
gives no information as to the immediate cause of death. 

* The last experiment gives no information as to the mode in 
which poisons circulating in the blood affect the body. Experiments 
by Verniere (Journal des Progres des Sciences Medicales, t. iii.) 
shew, that blood strongly impregnated with a poison, may be trans- 
fused from one animal to another, and produce its usual deleterious 
effects. 



OF CASES OF SUDDEN DEATH. 



21 



It is important to keep these cautions in mind when 
we apply the analogy of poisons to the elucidation of 
malignant diseases. They shew that although the blood 
be changed by the agency of the causes of these diseases, 
it does not necessarily follow that the obvious change in 
it is concerned in producing the most essential symptoms, 
or the fatal event. 

2. Another question which has been started on this 
subject is, whether the action of a poison, that has been 
absorbed into the blood, on the circulation itself, is to be 
ascribed to its direct contact with the heart and vessels, 
or in a great measure to an influence transmitted to 
them from the nervous system, which it must necessarily 
also pervade. On this point all that can be stated is, 
that we have clear evidence of the noxious effect of many 
poisons on moving solids to which they are directly ap- 
plied (e. g. on those of the fibres of the heart or intes- 
tines with which they are laid in contact), or even on 
vegetables ; but nevertheless, as we have seen that the 
action of all parts of the circulating system in animals is 
subjected to an influence or control, from changes taking 
place in their nervous system, it is quite possible^ that 
the agency of poisons, circulating in the blood, on mus- 
cular organs, and especially on the circulation, may be 
in part consequent on the impression which they make 
on the brain and nerves. And the order of the symptoms 
in the case of some such poisons, as the oxalic acid, 
would seem to denote that the primary effect is on the 
brain and spinal cord, and that the heart suffers second- . 
arily. 

3. The action of the different mortal poisons clearly 



22 OUTLINES OF PATHOLOGY AND PRACTICE. 

exemplifies two of tlie modes in wliicli it has been stated, 
that sudden death may be produced, i. e. the death by 
Coma, and the death by Syncope. Some poisons appear 
to act peculiarly on the lungs, but the only case in which 
they produce sudden death strictly in the way of As- 
phyxia, is that where certain gases, such as carbonic 
acid in full quantity, excite violent spasm at the glottis. 

a. Those which are called the Narcotic poisons, affect 
especially the nervous system ; and when acting in full 
force, produce the state of Coma, and death strictly in 
the way of coma, already described, the circulation con- 
tinuing, sometimes even tolerably strong, after the last 
breath is drawn, and then coming to a stand, because the 
respiratory movements are suspended, and the blood 
continuing venous, soon stagnates in the vessels of the 
lungs. 

This ultimate effect of these poisons is preceded in 
different cases, just as the ultimate fatal effect of injuries 
of the brain is, by various affections of the nervous sys- 
tem. Delirium, Convulsions, Vertigo, loss of different 
external senses, &c. ; or it may take place gradually, 
without any of these. After it, the blood is found ac- 
cumulated in the great veins, and on the right side of the 
heart, and the left is nearly empty. 

That this is the immediate cause of death in such 
cases, appears most clearly from the experiments of Sir 
B. Brodie in which the circulation was maintained bv 
artificial respiration, after the natural respiration had 
been suspended by the action of such poisons, until the 
impression which they had made on the nervous system 
had subsided, and the sensibility, and therefore the natu- 



* Phii. Trans. 1812. 



OF CASES OF SUDDEN DEATH. 



23 



ral respiration, were restored ; and the animals recovered 
from apparent, and wliat would otherwise have been 
real death. 

It is thus that, according to these experiments, alcohol, 
the essential oil of almonds, and tobacco, the juice of 
the aconite, and the woorara poison, produce death ; and 
the same is evidently the full and perfect action of opium, 
hyoscyamus, camphor, conium, and other medical agents 
commonly called Narcotics. 

But although the chief agency of these poisons is on 
the sensorium, i. e. on the brain, yet it is to be observ- 
ed, that they all appear more or less to weaken, and 
often irretrievably depress the action of the heart like- 
wise, and not merely by reason of their effect on respi- 
ration. And although there is one case on record,''^ 
where the fatal effect of opium on the human body was 
arrested by the artificial respiration, after the natural 
had failed ; yet, in general, the pulse becomes so feeble, 
the skin so cold, and the vital actions in the capillary 
vessels are evidently so much impaired, under the influ- 
ence of large doses of opium, before the respiration comes 
to a stand, that there is little ground for expecting that 
their fatal effect can often be arrested, even by this means, 
at so late a period. 

5. There are other poisons, the fatal effect of which 
is evidently exerted on the heart only, and which cause 
death merely by Syncope, — preceded by feebleness and 
often irregularity of pulse, by coldness, tremors, and 
failure of muscular power, and often by rigors, nausea, 
and vomiting, or by convulsions, as happens in many 
other cases of syncope. The unequivocal indications of 

* London Medical Observations and Inquiries, vol. vi. 



24 



OUTLINES OF PATHOLOGY AND PEACTICE. 



this kind of death are, that the respiration continues as 
long as the action of the heart ; and that the heart is 
therefore found, immediately after death, motionless, un- 
excitable by stimuli, and filled with venous blood on the 
right side, and arterial on the left, as in a living animal. 
It was thus that in the experiments of Brodie, death 
was produced by the upas antiar, and by the infusion of 
tobacco ; and the fatal effect of full doses of hydrocyanic 
acid, digitalis, strychnia, oxalic acid, arsenic, prepara- 
tions of antimony, and of baryta, various animal poisons, 
&c., appears to be of the same kind, although these 
poisons have a more complex operation, and affect a 
greater variety of organs. 

c. There are some vegetable, and many mineral poisons, 
which excite Inflammation, chiefly in the mucous mem- 
brane of the primee vise, but in some instances in other 
parts; and the symptoms of these inflammations (although 
rarely the sole effect of the poisons) blend themselves 
with those which proceed from the direct agency of the 
poisons on the nervous or vascular system, and in some 
instances the inflammation excited causes death, in modes 
to be afterwards considered. It is thus that many me- 
tallic, and some saline and earthy substances, and the dif- 
ferent vegetable and animal earths, are dangerous or fatal. 

d. In some cases the effects of poisons introduced in- 
to the system take place slowly, and last much longer, 
and are usually regarded simply as diseases, sometimes 
not to be distinguished from diseases which may be ex- 
cited by other means, and implying a similar danger ; 
as when arsenic produces epilepsy, lead colic and palsy, 
when the ergot of rye causes a peculiar kind of inflam- 
mation of the limbs, ending in dry gangrene, or different 
kinds of vegetable,s or tigh, urticaria, 



OF CASES OF SUDDEN DEATH. 



25 



The Gases which act as poisons iUustrate sufficiently 
these different modes of action ; chlorine, or nitric or 
muriatic acid gases, producing bronchial inflammation ; 
carbonic acid, or pure oxygen, acting as a narcotic ; and 
air itself, if introduced into the blood in any quantity, 
suspending the circulation, by the very peculiar manner 
in which it affects, and quickly stops, the actions of the 
heart. 

But although these different kinds of injurious or fa- 
tal action of poisons may be clearly distinguished, yet it 
is impossible to classify poisons strictly by their mode of 
action, because it is certain that the agency of almost all 
poisons is complex ; and that according to varieties of 
the dose, or mode of preparation, the same poison, on 
different occasions, may cause death in different ways, 
oxalic acid, e, g. in full doses, acting directly on the 
heart, but in smaller doses chiefly on the nervous sys- 
tem ; the essential oil of tobacco acting strictly as a nar- 
cotic, while the infusion of the leaves affects the system 
chiefly by its powerful sedative effect on the heart ; and 
arsenic, when taken in large quantity, producing its fatal 
effect on the heart, before there is time for the inflam- 
mation to be established, which constitutes the chief 
danger to be apprehended from smaller doses of the 
same poison. 

These statements are sufficient to illustrate the va- 
rious intentions, with which our scientific knowledge of 
the action of poisons demands that remedies should be 
applied to that action, and which may be thus enume- 
rated : 1 . The expulsion of the poison from the body by 
emetics or mechanical means. 2. The protection of the 
mucous membrane by diluents and demulcents. 3. The 



26 OUTLINES OF PATHOLOGY AND PRACTICE. 



use of chemical antidotes, as of albumen for corrosive 
sublimate, acids for alkalies, even ammonia for hydrocy- 
anic acid, &c. 4. The use of various stimuli, acting 
on the nervous system, for narcotics. 5. The use of 
stimuli for the nauseating poisons, such as digitalis for 
tobacco. 6. The use of antiphlogistic and anodyne re- 
medies for the irritant poisons. 

VI. In regard to the effects of dangerous or fatal 
Hcemorrhage in the living body, the following seem the 
most important facts. 

1. When the haemorrhage is very gradual, all the in- 
dications of failure of the circulation may come on, — the 
feebleness of muscular action, — the paleness and collapse 
of the countenance, — the coldness beginning at the ex- 
tremities, — the cold sweat beginning on the face, — and 
the pulse may become imperceptible, without the senses, 
or the intellect, being impaired ; and a slightly laborious 
or heaving respiration may be almost the only indication 
of injury of the nervous system up to the moment of 
death. Such perfect endurance of the functions of the 
nervous system, attending irretrievable depression of the 
powers of the circulation, is still more remarkably seen 
in some fatal diseases, where the heart's powers are de- 
pressed sympathetically in consequence of disease of 
other parts, than in cases of haemorrhage where the vi- 
tal stimulus is gradually withdrawn. 

2. A more sudden and violent haemorrhage affects the 
nervous system much more speedily, just as we have al- 
ready seen, than any other means of suddenly diminish- 
ing the pressure, to which the brain had. been subjected, 
does ; — and the impression thus made in the brain re- 



OF CASES OF SUDDEN DEATH. 



27 



acts on the heart after the manner of a concussion., and 
causes its action to fail mucli sooner than it would have 
done, merely by reason of the loss of blood. It is only 
in this way that we can explain the fact, that in bleed- 
ing from a large orifice, and in the erect posture, not 
I only sensation, and the other functions of the brain are 
sooner suspended, but the hearth own actions fail^ with 
much less loss of blood than when the orifice is small- 
er, and the patient lies horizontally, so that the dimi- 
nution of the pressure on the brain is less, and more 
gradual. 

In this manner death may be produced, certainly in 
much less time, and probably with less loss of blood, 
than by a more gradual haemorrhage ; and in such a case, 
the greater affection of the nervous system is shewn, 
sometimes by transient delirium, often by nausea and 
vomiting, and very generally by insensibility, and by 
more or less of spasms or convulsion, often repeatedly 
occurring before death. These two distinct varieties of 
the violent death by syncope, are important to be re- 
membered in speculations on the fatal tendency of seve- 
ral diseases. 

3. The loss of blood, especially if frequently repeated, 
has, on many constitutions, especially in women and 
children, a subsequent effect, which could not have been 
anticipated a priori^ of increasing the excitability of the 
vascular system (whether by reason of the impression 
made on the nervous system or not is doubtful), and so 
leading to a state of the system described as Heaction 
after the loss of blood, or as Prostration with Excite- 
ment ; in which, especially if any cause of febrile ex- 
citement at the same time exist, there is a fallacious 



28 



OUTLINES OF PATHOLOGY AND PRACTICE. 



degree of strength and frequency of the heart's action, 
when the other vital actions are feebly performed, and 
farther evacuation is dangerous.* 

All these dangerous effects by haemorrhage may, in 
some instances, be averted, by the prudent use of sti- 
muli, and of nourishment ; and the transfusion of 
healthy blood (of the same species of animal), into the 
bloodvessels, may be effectual in arresting the fatal 
effect of haemorrhage, not only when the power of the 
heart is rapidly sinking, but even after the heart's ac- 
tions have come to a stand from this cause, but proba- 
bly only within a few seconds after that time.f 

VII. In the case of death by Fasting^ more or less of 
inflammation of mucous membranes is always excited, 
apparently by reason of the deficiency of the natural 
protecting mucus ; and probably in connexion with this 
inflammation a febrile action is established, which ren- 
ders the case more complex than it would have been, if 
all the symptoms had depended simply on the gradually 
diminishing quantity of blood. Nevertheless, gradually 
increasing debility of the circulation, and of all functions 
dependent thereon, and consequent extreme emaciation, 
characterize this mode of death. Ultimately even the 
function of absorption is nearly suspended. The appear- 
ances after death formerly noticed, J observed in a body 

* See Burn''s Principles of Midwifery, p. 243. Armstrong on 
Typhus, &c. p. 548. Parry on the Arterial Pulse, Exp. 27. 
Marshall Hall on the Effects of Loss of Blood, p. 28. Travers 
on Constitutional Irritation, p. 501. 

t See Blundell, Researches, &c. 

I Physiology, p. 178. 



OF CASES OF SUDDEN DEATH. 



29 



free from other marks of disease, are nearly characteris- 
tic of this cause of death. 

The dm-atioii of life in such cases is very various, as 
might naturally be expected, when it is remembered, 
1. That a degree of febrile action is excited, the inten- 
sity of which will necessarily be very different in diffe- 
rent constitutions ; and, 2. That different living bodies 
are habitually dependent in very different degrees on the 
alternate vital actions of nutrition and absorption : Ac- 
cordingly, in general, fasting is best borne by those in 
whom these vital actions have been long languid ; and 
in some such cases it has certainly been borne for a 
period many times as long as that which has been fatal 
in others. 

The depressed state of the function of absorption it- 
self, after long continued fasting, is probably the reason 
why in such circumstances it has been found injurious 
to give large quantities of nourishment ; and frequent 
and small supplies have appeared more useful. 

VIII. It is unnecessary to enlarge on the phenomena 
of death by Asphyxia, or beginning at the lungs, whether 
by strangulation, suffocation, drowning, confinement in 
a gas that is not poisonous, but contains no oxygen, ex- 
posure of the surface of the lungs to the atmosphere, 
pressure on their surface, as by certain mechanical in- 
juries of the thorax, occlusion of their cells, or any other 
mode of obstructing the access of air to the blood of the 
pulmonary artery, while the other organs essential to life 
are uninjured. In all these cases there is a hurried 
and laborious action of the muscles of respiration, and 
more or less of lividity ; then insensibility with spasms, 
believed to depend on the contact of venous blood, which 



30 OUTLINES OF PATHOLOGY AND PRACTICE. 



has passed slowly and uiiclianged through the lungs, 
with the brain and nerves ; the respiratory efforts become 
irregular and then cease ; and on examination imme- 
diately after this, the heart is found still contracting, but 
its left side nearly empty, and the blood accumulated on 
its right side and in the lungs ; implying, that although 
some blood is transmitted unchanged to the left side of 
the heart, and thence sent over the body, yet it makes 
its way slowly and imperfectly through the capillaries 
of the lungs, and at length stagnates there, when it is 
not arterialized. 

This accumulation on the right side of the heart is 
especially observed, when death has been produced most 
slowly in this way, because then there is time for much 
of the blood from the body at large to reach the heart, 
before the final stop to its passage through the lungs. 

It is important to remember the occurrence of insen- 
sibility, and often of spasms, before the circulation 
comes to a stand, or is even very much weakened, as il- 
lustrating what happens in many diseases affecting the 
functions of the lungs. 

It is important to remember also, that the circulation 
comes to a stand before the heart has lost its power, as 
this is the foundation for the practice by which resusci- 
tation from apparent death of this kind has often been 
accomplished, even some minutes after pulsation has 
ceased. Of that practice, notwithstanding some diffi- 
culties that have been started on the subject, it may still 
be maintained that the artificial respiration is the most 
essential part ; — the other remedies being various modes 
of applying internal and external stimuli. 

It may easily be believed, from what has been stated, 
that after such resuscitation, distress, and even danger, 



OF CASES OF SUDDEN DEATH. 



31 



may result from the congested state of the hmgs, and 
therefore that bloodletting may be useful in such cases, 
even before the circulation and animal heat are effec- 
tually restored in the extremities. 

The tendency to a fatal termination in the different 
diseases, and in different stages or circumstances of the 
same, is very different, and often complex ; but is al- 
ways susceptible of illustration by reference to the 
simpler cases of violent death now considered. And it 
is of especial importance to keep in mind these different 
modes of fatal termination in those diseases (such as 
F'ever) which admit of the gTeatest variety, in which dif- 
ferent dangers threaten on different occasions, and in 
which various kinds of treatment are recommended j 
because it is only by anticipating the kind of fatal ter- 
mination which is most probable in each case, that we 
can expect to be guided to a rational and scientific selec- 
tion of remedies. 



( 32 ) 



CHAPTER II. 

OF DISEASES IN GENEKAL— THEIR FATAL TERMINATIONS, 
OR SPONTANEOUS DECLINE. 

Those conditions of the animal economy to vfhich we 
give the name of Diseases, differ from the effects of 
violent or fatal injuries, chiefly in the following cir- 
cumstances : — First, That they frequently originate 
without any obvious exciting cause ; secondly, That they 
are not uniformly excited, where the causes to which we 
ascribe them are applied ; and, thirdly, That they al- 
ways consist of certain series and successions of changes, 
usually first shewing themselves some time after their 
exciting causes have been applied, and always lasting 
long after that application has ceased. 

It is necessary here, first, to attend to the distinction 
between the strictly scientific or pathological, and the 
nosological meaning of the term Disease. According to 
the first meaning, the term is applied to any such 
alteration of vital actions going on within the body, as 
causes suffering or danger ; and the name of any indivi- 
dual disease is applied as accurately as possible to the 
primary and fundamental change, from which the other 
changes and all the symptoms naturally follow, either 
according to the Laws of Physiology, or according to 
principles which are ascertained in the Science of Pa- 
thology itself. According to the second meaning, the 
term is applied to a particular set of symptoms, occurring 
so similarly in different individuals, that they are judged 



OF DISEASES IN GENEEAL. 



33 



to cliaracterise a single diseased condition of the body, 
independently of any speculation as to tlie nature of that 
condition. 

In this strictly nosological view of diseases, symptoms 
are carefully observed and compared, — whether uneasy 
sensations, — or alterations of the sensible qualities of the 
living body, — or of the functions of its different parts ; 
certain combinations and successions of these, frequently 
occurring together, are formed into Genera, and then by 
a farther selection of the most general and characteristic, 
and exclusion of the more special and variable, these are 
arranged in orders or Classes, still without reference to 
the nature of the actions producing them. This process 
of classification was very properly begun, and carried to 
a certain degree of perfection, for practical purposes, 
before any considerable progress had been made either 
in Physiology or Pathology. But this mode of proceed- 
ing is never found sufficient as a guide for practice. By 
such arbitrary rules, cases are brought together, which 
appear distinctly, from their progress, and from the ap- 
pearances on dissection, to be essentially different, and 
to demand different treatment ; and again, cases are 
widely separated which depend on the same fundamental 
diseased action. Accordingly, it is very often found in 
practice, that the nature of the most urgent symptoms 
(ascertained, or even conjectured), is of much more im- 
portance, as guiding the use of remedies, than the mere 
names of diseases. 

The practice of medicine, therefore, never was con- 
ducted on the strictly empirical plan, i. e. without any 
reference to Pathology ; and as this latter science makes 
progress, the characters of diseases, to which practitioners 
refer, are gradually accommodated to it, so that the no- 

c 



34 OUTLINES OF PATHOLOGY AND PRACTICE. 



sological cliaracters in use, and the pathological distinc- 
tions of diseases, approach nearer to one another. 

We have no reason to think, however, that these will 
ever completely coincide ; because the true Pathology 
of many cases of disease, even when well understood, 
becomes obvious only in their advanced stage, or even 
after death ; and farther, because under the varying cir- 
cumstances of different individual cases, the same fun- 
damental lesion may lead to results so different, and so 
important, as to demand, for practical purposes, distinct 
names; and conversely, different fundamental lesions may 
make themselves known by appearances so exactly simi- 
lar, that we cannot, in practice, give them different 
names. Thus, the same diseased state of the arteries 
may make itself obvious, in different persons, by Pal- 
pitation, by Dyspnoea, by neuralgic pains of the chest, 
by Apoplexy, or by Dropsy ; and again the characteris- 
tic symptoms of Apoplexy, Palsy, Epilepsy, Jaundice, 
Dropsy, &c., may require us to give those names to many 
individual cases, although we know, from Pathology, that 
these states are only to be regarded as symptoms, and 
that each of them may occur in the course of different 
morbid actions, of which the origin and course are per- 
fectly distinct. Even the state of Fever requires often 
to be recognized and named, while it is still uncertain 
to what kind of diseased action, or to what head of a 
nosology, it ought to be referred. 

A little farther consideration shews, that there are 
many combinations and successions of symptoms, which 
it is practically important to study, but which are quite 
distinct from those on which any arrangements of dis- 
eases are founded. Such are those which we express by 
the terms Tendency to Syncope, Comatose tendency, Ty- 



OF DISEASES IN GENERAL. 



35 



phoid tendency, Inflammatory tendency, Scrofulous dia- 
thesis. Putrescent diathesis, Heemorrhagic diathesis, 
Nervous irritability, &C.— conditions of the body which 
may be accurately distinguished, but each of which is 
often observed in the course of many different diseases. 

In fact, Nature does not present us, in almost any case, 
with Diseases — whether distinguished by their symptoms 
or their intimate nature — as clearly defined and sepa- 
rated from each other, as the genera and species of plants 
or animals ; but with deviations from the natural state, 
graduating into one another by insensible degrees (some- 
what as miner alogical specimens of the compound rocks 
do)j and admitting of useful comparison with one ano- 
ther, not simply because recognised as identical, but be- 
cause judged to resemble one another strongly in their 
most important characters. 

It does not therefore appear possible, either to have 
a perfect Nosology, or to supersede the arrangements of 
nosology, by a strictly pathological classification of dis- 
eases ; but those arrangements must necessarily be mo- 
dified from time to time, and made to conform as accu- 
rately as possible to the results of scientific inquiries into 
the essential nature of morbid actions. 

We arrange the cases of disease which present them- 
selves to our view, according to the symptoms which 
appear to characterize them most generally, soonest, 
and most decidedly ; but in making the arrangement, we 
keep constantly in view the real nature, so far as ascer- 
tained, of the diseased actions themselves ; and we ad- 
mit that all these distinctions are to a certain degree 
arbitrary, and not uniformly observed by Nature. Never- 
theless, the following distinctions appear of primary im- 
portance. 



36 



OUTLINES OF PATHOLOGY AND PEACTICE. 



1. All diseases may be arranged as Febrile and Non- 
Febrile (which latter term is more strictly applicable 
than Chronic.) 

Of Febrile diseases the great division is into, 1. In- 
flammatory diseases or Phlegmasise ; and, 

2. Fevers properly so called. 

Of Inflammatory Diseases, in all parts of the body, 
there are two great divisions — 
(a.) Into Acute and Chronic. 
(6.) Into Simple and Specific. 

We arrange the Inflammatory diseases, simply accord- 
ing to the parts of the system in which they are prima- 
rily and chiefly seated, into Inflammations of the Brain, 
Nervous System, and Organs of Sense — of the Air-pas- 
sages and Lungs — of the Heart and Bloodvessels — of 
the Digestive Org-ans — of the Urinary and Genital Or- 
gans — of the Integuments — and of the Organs of Loco- 
motion. While considering these, we might proceed, 
in connexion with the chronic form of each, to treat of 
the non-febrile diseases of the same parts or organs ; 
but it appears, on the whole, more important to treat 
next of the other great class of Febrile diseases. 

The Fevers, resulting from morbific Poisons, we di- 
vide into — 

(a.) Intermittent and Remittent. 

(h,) Continued. 

(c.) Eruptive. And in regard to each of these, we re- 
cognise farther distinctions, less accurately defined, but 
highly important, into 

Inflammatory and Typhoid ; and into 

Simple and Complicated, i. e. complicated with local 
inflammations not essential to their nature. 



OF DISEASES IN GENERAL. 



37 



II. Hesuming, then, the arrangement of the parts 
and organs which we had adopted in the Inflamma- 
tions, we study the Non-Febrile diseases which are pri- 
marily or chiefly seated in each of them. And among 
these we can point out peculiar distinctions as important 
as those drawn in the other classes. These are the dis- 
tinctions of Functional and Organic diseases ; the lat- 
ter term being applicable only when, in consequence of 
previous diseased actions, an obvious change of some 
tissue, implying permanent derangement of function, has 
taken place in some part of the living frame ; — and again 
the distinction of simply organic and Malignant disease, 
the latter term being applied when not only the organ- 
ized structure has undergone a change, but a matter fo- 
reign to the healthy condition of the body has been in- 
troduced into it, the formation of v/hich is often rapidly- 
extended. 

Our knowledge of the real nature of the changes on 
which all these manifestations of disease depend, is, of 
course, derived partly from observation of the symptoms 
which shew themselves during life, and reflection on the 
import of these symptoms, as made known to us by Phy- 
siology ; and partly also from the morbid appearances, 
or alterations of structure apparent in the dead body, 
which are the effects of the diseased actions, and which 
often satisfactorily explain their fatal termination. 

We may observe, however, that the organic changes 
of structure apparent in the dead body after disease (and 
w^hich are subject to less variety, and more easily de- 
scribed and arranged than the symptoms of diseases), 
have been regarded too exclusively by some as the only 
sure basis of all pathological discussions ; and the accu- 
rate description and arrangement of these have been 



38 



OUTLINES OF PATHOLOGY AND PRACTICE. 



thought to be the main object of Pathology, which is 
thus rendered nearly a synonymous term with Morbid 
Anatomy. 

The following considerations seem sufficient to shew, 
on the other hand, that the study of organic lesions, al- 
though an essential, can form but a small part of a ra- 
tional and useful system of Pathology. 

1. There are very numerous cases, arranged into dif- 
ferent genera of disease, some of them important, and 
even rapidly fatal, e. g, different forms of fever, certain 
cases of apoplexy, and of syncope, tetanus, &c. which do 
not uniformly or necessarily leave behind them, so far 
as is yet known, any alteration of textures, or other 
change, perceptible to the anatomist ; the Pathology of 
which diseases, therefore, although it may derive assist- 
ance from, cannot possibly be founded on, the knowledge 
of morbid appearances. 

2. In many cases of disease, where decided alterations 
of structure are found after death, these cannot be con- 
nected with the fatal event, and do not furnish a rational 
explanation of it, without reference to general facts or 
principles, known to us simply by the previous observa- 
tion of disease, and by generalization of facts which that 
study presents. It is only by such observation that we 
learn, that a certain amount of inflammation on the pe- 
ritosenum furnishes an adequate explanation of fatal de- 
pression of the heart's action ; or even, that a certain 
extent of ulceration of the lungs is sufficient to explain 
a wasting hectic fever.* In such cases, it is obvious 

* Jouent-elles un role important dans Teconomie animale, les 
membranes sereiises qui tapissent quelques visceres ? Leur lesion 
traumatique est-elle immediatement mortelle, comme Test, par ex- 
ample, celle de quelques parties de rencephale ? Certainement non ; 



OF DISEASES IN GENERAL. 



39 



that the laws, according to which such lesions become 
injurious or fatal, as they cannot be deduced from the 
study of the lesions themselves, demand a separate in- 
vestigation. 

3. Even in those cases where the morbid structures 
that are ascertained to exist before death, or found after 
death, easily and satisfactorily explain the symptoms in 
the latter stages of the disease and the death of the pa- 
tient, it is obvious that these alterations of structure 
must themselves have resulted from previous diseased 
actions^ i. e, that every disease must necessarily have 
been one of function^ before it could become one of struc- 
ture. The main object of inquiry is into the essential 
conditions and intimate nature of these diseased actions ; 
and although all the information we can acquire in re- 
gard to them is necessarily limited, and liable to various 
sources of fallacy, yet the study of the diseased struc- 
tures, which are their effect and indication, has little 
value, either with a view to Pathology or to Practice, 
except in so far as it tends to give some insight into the 
nature of the diseased actions themselves. 

These considerations are sufficient to shew that Pa- 
ct pourtant voyez les suites qu'entraine leur inflammation. Serait 
ce r injection de leurs capillaires qui aurait donne la mort ? Serait 
ce la couche de lymphe coagulable qui tapisse la surface lisse de ces 
membranes ? Qui le croira ? II y a done encore autre chose dans 
ces cas que ce qui tombe sous les yeux. II y a, independamment 
des elemens materiels, un agent vital a signaler et etudier, Et 
neanmoins que trouve t'on dans les ouvrages d'anatomie patholo- 
giques d'ailleurs si justement estimes ? Les recherches les plus pre- 
cieuses sur I'etat des tissus, I'examen le plus scrupuleux de leurs 
proprietes physiques et chimiques, le rapprochement le plus exact 
des phenomenes de la maladie avec les alterations organiques ; mais 
pen de considerations physiologiques sur la pathogenie de ces derniers. 
Or, il est tres essentiel de s'occuper de ces considerations, a fin de 
donner a tous ces travaux le complement qui leur manque. — Lob- 
stein, Traite d'Anatomie Pathologique, liv. i. § 299. 



40 OUTLINES OF PATHOLOGY AND PRACTICE. 



thology, or the study of diseases, cannot be made to as- 
sume the form of a science, without careful investigation, 
and reference to general laws ; 1. Of those morbid actions 
which produce no lesions of structure ; 2. Of those which 
precede, and cause such lesions ; and, 3. Of those which 
are produced by, and succeed such lesions, or attend their 
formation. 

In fact, neither the study of Physiology, the study of 
symptoms as they appear during life, nor the study of 
organic lesions discoverable after death, is sufficient in 
itself to enable us to deliver the history and explanation 
of the phenomena of disease ; but information from all 
these sources must be collected and combined for this 
purpose. 

In the last result, all the diseased actions now enume- 
rated may probably be ascribed to changes in those Vital 
Affinities, by which the minutest particles of animal bo- 
dies, both solid and fluid, are continually actuated during 
life, and by which the fundamental functions of assimila- 
tion and nutrition are regulated. The function of cir- 
culation and all the obvious moving powers of the ani- 
mal economy" are, in general, affected only secondarily, 
as a result of those primary changes, sometimes partial, 
and sometimes more general, in the vital affinities. It 
seems to be well ascertained, that in connection with these 
changes in the affinities subsisting among the minutest 
particles of the living solids and fluids, there are peculiar 
Attractions and Repulsions by which, rather than by any 
affection of the contractile powers of the living solids, 
many of the obvious changes in the distribution of the 
blood occurring in disease are determined.* 

* This doctrine has been represented as hypothetical, but is 
gradually making its way, as the intimate nature of diseased actions 



OF DISEASES IN GENEEAL. 



41 



The numerous and careful microscopical observations 
lately made on the minute structure of animal substances 
in health and disease afford a prospect of more precise 
information than we have yet had, as to the intimate na- 
ture of diseased actions. But all such information will 
necessarily be imperfect, until we shall attain to the know- 
ledge of some of those laws, by which the chemical affi- 
nities of the component parts of living bodies are conti- 
nually modified during the living state, and the forma- 
tion of those compounds, which are peculiar to living 
bodies, is determined. 

But there are two practically important points to be 
studied in regard to all these kinds of diseased actions, 
first, The modes of fatal termination to which tliey tend, 
and, secondly, The provisions of Nature for their spon- 
taneous decline, — concerning which we have much more 
satisfactory information than concerning their intimate 
nature. 

The tendencies of different diseased actions to their dif- 
ferent fatal terminations are obviously susceptible of il- 
ls made out by the aid of the microscope. " The changes constantly 
going on in the blood are attended with variations in the capabilities 
of the corpuscles for Endosmose, and in their attractions and repul- 
sions. These appear to be the cause of the variations which are 
constantly occurring in the capillary circulation. The force of the 
heart alone, and not any action of the capillaries, determines the 
general passage of the blood from the arteries into the veins, but it 
is to the attractions and repulsions of the corpuscles that the varied 
peculiar movements of the blood in the capillaries are owing. In 
considering the circulation through the capillaries, in short, it is al- 
ways to be remembered that the blood is not a mere inert fluid, but 
one containing in suspension innumerable organized and living cor- 
puscles endowed with peculiar attractions and repulsions." — Whar- 
ton Jones in British and Foreign Med. Keview, vol. xiv. p. 600. 



42 OUTLINES OF PATHOLOGY AND PEACTICE. 



lustration (as already observed) by reference to tlie sim- 
pler cases of sudden and violent death already considered ; 
and it is of the utmost importance, in all truly scientific 
practice, to keep them constantly in view : but it is al- 
ways to be observed, that, in the course of the same dis- 
ease, and even at different periods of the same case, death 
may be threatened in very different ways. This is espe- 
cially remarkable in regard to the strictly febrile diseases. 

Generally speaking, in the most rapid or acute diseases 
of different parts (especially internal parts) of the body, 
whether febrile or not, death is threatened in like man- 
ner as by mechanical injury of the same parts ; and it 
is very often sufficiently explained by the injury done to 
the structure, and consequent interruption of the func- 
tion of the part. Thus, in the acute diseases of the 
Head, we are threatened with the fatal termination by 
Coma, in those of the Chest by Asphyxia, and in those 
of the Abdomen by Syncope (or sympathetic affection 
of the heart), just as in injuries of these divisions of the 
body. In the more chronic diseases of the same parts, 
death is produced in a more complex manner, partly by 
the disturbance of the function of the part, but partly 
also by the constitutional disturbance, e. by the disor- 
der of the general function of assimilation, or by the 
exhausting evacuations, consequent on the continuance 
of the local diseased action, rather than on its local 
results ; and illustrated by the effects of starvation, or of 
haemorrhage, rather than of more violent injuries. 

In the case of certain local diseases, particularly of 
the Liver and Kidneys, a very peculiar mode of fatal 
termination is sometimes observed, in consequence of 
the local disease leading to retention of the natural ex- 
cretions, and thereby affecting the system as a narcotic 



OF DISEASES IN GENERAL. 



43 



poison. And it is also certain, that death from any of the 
strictly febrile diseases, and from certain of the inflam- 
mations which we term specific, is owing, in part, some- 
times almost entirely, to the influence of causes which 
affect peculiarly the fluids of the body, without alter- 
ing the structure of any of its solid parts, and produce 
changes analogous in the most important respects to the 
agency of poisons on the animal economy. 

It is also easy to understand, that, in the course of dis- 
eases, both acute and chronic, complications of diff*erent 
kinds of morbid action, and of morbid changes in diflbr- 
ent parts of the body, often take place ; sometimes from 
accidental causes, but frequently also in consequence of 
known laws, whereby the living actions of diff'erent parts 
of the body are connected together ; and that death 
is therefore often owing to a combination of different 
causes, the operation of each of which may be accurately 
observed, although its exact amount may not be easily 
assigned. The history of Dropsy, in connection with 
organic diseases of diff'erent internal parts, furnishes con- 
tinual illustrations of this observation. 

The tendency of most diseases, both acute and chro- 
nic, to a spontaneous favourable termination, has been so 
often and so distinctly observed, as to have suggested the 
doctrine of a Vis Natura3 Medicatrix constantly resident 
in the living body. This term is decidedly objectionable, 
as implying either mere fanciful speculation, — or the 
substitution of the final for the physical cause of changes 
observed in the body. But it is of the highest impor- 
tance both to know the fact, and to understand the mode, 
of such salutary changes gradually and spontaneously 
taking place in the course of diseases ; and the following 



44 



OUTLINES OF PATHOLOGY AND PRACTICE. 



may be stated as the chief principles to which such 
changes are to be ascribed. 

1. The effects of some of the external causes of dis- 
ease are naturally transient, and the diseased action, kept 
up only by the action of that cause, subsides soon after 
its discontinuance. This is especially the case with dis- 
orders primarily affecting the circulation of the blood 
in the larger vessels, and its distribution to tiifferent 
parts of the body ; and with those in which the nervous 
actions are at fault, as affected, e. g. by muscular exer- 
tion, by mental emotion, even by the sensations of heat 
and cold under certain circumstances, &c., independent- 
ly either of inflammation or organic disease. Again, 
the substances strictly called Poisons, of the vegetable 
and animal kingdom, if not taken in excessive quantity, 
and many injurious substances taken into the stomach, 
are decomposed in the system, and expelled with the dif- 
ferent excretions, and their noxious effects then disap- 
pear. 

2. In the greater number of cases, where the remote 
causes of disease have been applied, or the strictly mor- 
hijic poisons been imbibed, the diseased action thus set 
up continues long" after the causes are withdrawn, but is 
nevertheless essentially temporary. As we know that 
all vital action is but of limited duration in any struc- 
ture in which it resides, and that a general law of 
intermittence of action, or alternation of activity with re- 
pose, applies to all the changes going on in the healthy 
state of muscles and nerves, as well as in the diseased 
actions peculiar to these parts, we cannot be surprised to 
find, that other and more obscure morbid actions should 
be subject to a similar law ; and in fact, we cannot at- 
tribute to any other cause (?. e. we cannot refer to any 



OF DISEASES IN GENERAL 



45 



otlier more general fact) the spontaneous decline either 
of the local changes which constitute inflammation, or 
of the more general changes which produce idiopathic 
fever ; or the slower and less complete, but still percep- 
tible remissions of the morbid actions often observed in 
chronic and even in organic diseases. 

3. In the case of local injury done by diseased ac- 
tions in different parts of the body, we can often point 
out more precisely, the provisions of nature for repair- 
ing the injury, or remedying its effects. Thus the ten- 
dency of inflammation to deposition of organizahle lymph^ 
is the main part of those provisions of nature, by which 
most haemorrhages are stopped, and the injury which 
might be done to parts of the body, either by the causes 
exciting inflammation, or by certain results of the in- 
flammation itself, and particularly by the formation of 
pus, is prevented or repaired. Again, the liquefaction 
of the products of inflammation into purulent matter, 
which may be discharged from the body, and the ab- 
sorption of a great part of all the inflammatory efiPusions 
after the process of inflammation is over, are changes 
essential to the restoration of the healthy state of parts. 
In the case of mortification or sloughing, all these pro- 
visions are successively required for the recovery from 
the lesion that has taken place. 

Another provision by which the injury done to indi- 
vidual parts of the body, both by inflammation and 
other diseases, is obviated in various cases, is the ob- 
struction to the circulation through them, and the in- 
creased flow to, and increased development of, neigh- 
bouring or corresponding parts, by which the place of 
the injured organ is supplied. 

The state of hypertrophy into which the heart and 



46 



OUTLINES OF PATHOLOGY AND PRACTICE. 



other muscular organs are brought, by the existence of 
any cause which obstructs the result of their natural ac- 
tion, is another provision by which the injurious effects 
of very common diseases are lessened or retarded. 
And we are by no means entitled to set aside the sup- 
position of many pathologists, that the state which we 
call Febrile Reaction, is a provision by which the or- 
gans of circulation are excited to resist the noxious ef- 
fects of causes which would otherwise irretrievably de- 
press their action, in like manner as the state of hyper- 
trophy is that, in which the heart permanently reacts 
aoainst causes which would otherwise arrest the flow 
of the blood. 

All these are proofs (similar to many which we meet 
with in Physiology), not of a peculiar healing or con- 
servative power being lodged in animal bodies, but of 
the general laws of the animal economy being so insti- 
tuted, that many causes of injury, which would other- 
wise be fatal, are resisted and overcome. 

The knowledge of these salutary provisions of na- 
ture, of the circumstances in which they are to be ex- 
pected, and the conditions essential to their taking ef- 
fect, is of course of the utniost importance, both as to 
Prognosis and Practice. 



( 47 ) 



CHAPTER III. 

OF THE REMOTE CAUSES OF DISEASES IN GENERAL, AND 
THE MEANS OF THEIR PREVENTION. 

The living body assumes, in many cases, different 
kinds of diseased action, — varying remarkably in diffe- 
rent periods of life, — without any apparent or known 
cause ; but in the greater number of cases, it is generally 
believed, that certain circumstances in the situation or 
condition of patients, before diseases appear, can be as- 
signed with confidence as their causes. The efficacy of 
these, however, is seldom established in any other way 
than simply by the observation, that persons known to 
be exposed to their influence, become afflicted with cer- 
tain diseases in a proportion very much greater than 
those who are not known to be so exposed. 

This kind of evidence is in many individual cases very 
liable to fallacy, in consequence of the great variety of the 
circumstances, capable of affecting health, in which indi- 
viduals are placed, and of the difficulty of varying these, 
so as to obtain such observations, in the way of induc- 
tion, or exclusion, as shall be decisive as to the efficacy 
of each. Hence the importance of the observations, in- 
tended to illustrate this matter, being as extensively 
multiplied as possible ; and hence also the peculiar va- 
lue, Avith a view to the investigation of the causes of dis- 
eases, of observations made on large and organized bodies 
of men, as in the experience of military and naval prac- 



48 OUTLINES OF PATHOLOGY AND PRACTICE. 



titioners. All the circumstances of the whole number 
of men, whose diseases are there observed, are in many 
respects exactly alike ; they are accurately known to the 
observer, and are indeed often to a certain degree at his 
disposal ; they are often suddenly changed, and when 
changed as to one portion of the individuals under ob- 
servation, they are often unchanged as to another ; and 
therefore, the conditions necessary to obtaining an expe- 
rimentum crucis as to the efficacy of an alleged cause of 
disease, are more frequently in the power of such an ob- 
server, than of one who is conversant only with civil life. 

But when the necessary precautions, as to the multi- 
plication of facts, and the exclusion of circumstances fo- 
reign to the result in question, are observed, the efficacy 
of the remote causes of disease may often be determined 
statistically, and with absolute certainty ; and the know- 
ledge thus acquired, as leading directly to the prevention 
of disease, is often of the greatest importance, especially 
with a view to regulations of Medical Police. And if 
the human race be destined, in future ages, to possess 
greater wisdom and happiness in this state of existence 
than at present, the value of this knowledge may be ex- 
pected to increase in the progress of time ; because there 
are many diseases which the experience of ages has 
brought only partially within the power of medicine, but 
the causes of which are known, and under certain cir- 
cumstances may be avoided ; and the conditions neces- 
sary for avoiding them are in a great measure in the 
power of communities, though at present beyond the 
power of many of the individuals composing these. 

There are, indeed, various cases, of frequent occurrence, 
in which the study of the Remote Causes of Disease is as 
practically important as any thing that can be learnt as 

2 



OF THE REMOTE CAUSES OF DISEASE. 



49 



to their history, or the effects of remedies upon them. 
This is particularly true of Epidemic Diseases, and of 
diseases to which a tendency is given by irremediable 
constitutional infirmities. 

Under the head of Remote Causes of Disease, we in- 
clude not only causes acting externally to the body, but 
also circumstances in the condition of the body itself, 
previous to the attack of disease in question, which are 
believed to assist in exciting it ; and of the mode of ope- 
ration of these last, we have often more satisfactory in- 
formation than of external causes. Some general ob- 
servations on this subject will put it in a clearer point 
of view, than more detached and incidental statements 
in delivering the history of diseases would do, and will 
save repetition in future. 

The Remote causes of disease are commonly divided 
into Predisponent and Exciting, the former of which 
have been long in operation before the disease appears, 
the latter immediately precede its appearance. It is im- 
possible to distinguish them accurately in all cases ; but 
nevertheless, this distinction, and especially the very fre- 
quent concurrence of causes of both kinds in producing 
disease, must be carefully kept in mind. This, indeed, 
may almost be inferred from the general fact formerly 
stated, that the operation of causes of disease is never 
quite uniform, and often subject to very great varieties. 

Thus, the hereditary nature of certain diseases (i. e, 
the peculiar tendency or disposition to them given by 
hereditary descent) is well ascertained ; but some occa- 
sional external cause very generally excites the disease, 
to which there is this predisposition ; and those who at- 
tend only to the obvious operation of the exciting cause, 
are apt in this and other instances to overlook the evi- 



50 OUTLINES OF PATHOLOGY AND PRACTICE, 

deuce by which the efficacy of the predisponent is esta- 
blished. 

Again, unless we attend to the very frequent concur- 
rence of different causes in producing disease, we may 
readily misapprehend the evidence of the efficacy of a 
powerful exciting cause, as cold, contagion, or malaria^ 
if we shall see it repeatedly applied to persons not pre- 
disposed to suffer from its effects, and taking effect only 
on those in whom its operation is aided by some latent 
predisposition, or some concurrent and accessory cause. 
Both these errors have very often occurred in medical 
inquiries as to the remote causes of disease, and the 
means of preventing them. 

I. The following may be stated as the chief Predis- 
ponent Causes of disease, that is, the circumstances to 
which we can in general refer the tendency observed in 
certain individuals, more than in others, to fall into dis- 
ease on the application of the exciting causes, to be af- 
terwards enumerated. 

1, The transmission of the tendency to certain diseases 
from parents to children, is only part of the general fact 
of the influence of the constitutional peculiarities of pa- 
rents on their offspring.* But there are certain kinds of 
diseased action where this predisposition from hereditary 
constitution has been peculiarly observed ; these are, cer- 
tain well-marked varieties of inflammation, termed the 
Scrofulous and the Gouty, — certain kinds of morbid for- 
mations, especially the scrofulous tubercles, — and cer- 
tain forms of diseases of the Nervous System, Asthma, 
Epilepsy, and Mania. Of these, the scrofulous affec- 



* Physiology, p 30?. 



OF THE REMOTE CAUSES OF DISEASE. 



51 



tioiis only are in a few instances congenital^ as well as 
hereditary ; and the appearance of the others is fre- 
quently determined more by the application, and often 
the concurrence, of other causes, than by the circum- 
stance of hereditary predisposition in those who possess 
it. There are many other diseased states, however, 
even disorders of Nutrition or Secretion, or of the gene- 
ral function of Assimilation, often distinctly observed to 
be hereditary, e, g. diseases of the large arteries, with all 
their different consequences, Gravel, and Diabetes.* 

Although we have no means of correcting this origi- 
nal predisposition, the knowledge of the fact is of great 
value to such persons, as shewing the importance of 
avoiding, or fortifying the constitution against, the ap- 
plication of exciting causes, which very often co-operate 
with that tendency to produce disease. 

2. There are many causes very often observed to pre- 
dispose to disease, which may be ranked together, as 
their obvious effect on the system is very much alike. 
They tend, whether acting singly or several in conjunc- 
tion, to enfeeble the vascular action in the hody^ and per- 
haps especially that in the extreme capillaries ; and at 
the same time, they render the nervous system more sus- 
ceptible of impressions from without. Thus they dis- 
pose the body to suffer, and especially the vascular ac- 
tion to become disordered, from the application of ex- 
citing causes, either of acute or chronic disease, which 
might be otherwise innoxious. But it does not ap- 
pear that these predisposing causes of themselves de- 
termine either the kind or the seat of the diseased ac- 
tion which is to ensue : — they are often observed to pre- 

* See Holland's Medical Notes and Reflections, chap, ii 



52 



OUTLINES OF PATHOLOGY AND PRACTICE. 



cede, and believed to assist in producing, very different 
kinds of diseased action, which may be seated in differ- 
ent textures or organs, according to the original or ac- 
quired peculiarities of individual constitutions. These 
may be divided into causes of deficient excitement, and 
causes of excessive or exhausting excitement. 

Of the first kind are, 

(a.) Imperfect nourishment. 

[b.) Deficiency of the natural stimuli of pure air, and 
of muscular exercise. 

(c.) Long-continued cold, not sufficiently counteracted 
bv artificial warmth or muscular exercise. 

(6?.) Excessive and repeated evacuations, either of 
blood or of the serous part of the blood. 

(g.) Depressing passions of the mind, especially those 
which are of the longest continuance. 

(/.) Previous debilitating disease, whether acute or 
chronic. 

Of the second kind are, 

((/.) Excessive exertion, mental or bodily, with defi- 
ciency of the natural relaxation of sleep. 

(/?.) Long-continued heat, with little of the invigo- 
rating influence of occasional reduction of temperature. 

(?'.) Intemperance, i. e. the frequent use of strong li- 
quors, in such quantity, that their first or exciting effect 
on vital action is more than counterbalanced by their 
more permanent depressing effect. 

Ample experience, not only of what occurs within the 
observation of individuals, but more especially that which 
is afforded by statistical returns, — of the amount of dis- 
ease and mortality in great towns, and chiefly in the 
worst aired parts of towns, as compared with agricultu- 
ral districts ; — in sea^^ons of scarcity as compared with 



OF THE REMOTE CAUSES OF DISEASE, 



53 



seasons of plenty ; — among the most indigent classes of 
society, as compared with those in comfortable circum- 
stances ; — among the poorest inhabitants of hot or very 
cold climates, in circumstances where persons who have 
been more habitually protected from the extremes of 
temperature retain their health ; — among convalescents 
from acute diseases, as compared with persons previously 
healthy ; — among the intemperate as compared with the 
sober ; — in beaten armies, or among depressed and dis- 
heartened individuals, as compared with victorious ar- 
mies, or more fortunate and flourishing members of so- 
ciety, — establishes beyond all doubt the efficacy of these 
various debilitating causes, in augmenting the amount 
and fatality of disease ; and, of course, establishes also the 
importance of a truly Tonic Regimen (of which, nourish- 
ing diet, pure air, habitual exercise, mental excitement, 
and the occasional prudent application of cold, are the 
essential parts), in fortifying the constitution against 
many kinds of disease. The mode of life of the most 
destitute of our species is, in all the respects above stat- 
ed, much more weakening than that of those who are 
more comfortably situated ; and accordingly, it appears 
certain, that no circumstance in the condition of man- 
kind so uniformly increases mortality as destitution, par- 
ticularly in large towns.* 

Some of the causes above enumerated peculiarly affect 
particular organs,^ — as heat the liver, and mucous mem- 
brane of the bowels, excessive mental exertion the brain, 
violent mental emotion the heart, &c. — and dispose 
them more than other parts to suffer from the applica- 

* See particularly Keport of Villerme on the Mortality of the 
different Arrondissemens of Paris. — Archives de Med., 1825. 



54 OUTLINES OF PATHOLOGY AND PRACTICE. 



tion of exciting causes of disease. Others of the causes 
in question have a peculiar tendency to produce certain 
kinds of inflammation, as the air of low, damp, and 
crowded habitations, to determine the scrofulous form 
of inflammation. 

But there is no one organ or texture which is uni- 
formly affected, nor anyone kind of diseased action which 
is uniformly excited, by any of these causes. Their ge- 
neral effect is, to dispose the body to suffer from the ap- 
plication of the exciting causes of inflammation, or of 
other acute diseases ; and farther, especially when they 
are long applied, to dispose the body to those kinds of 
chronic disease which commence by the deposition from 
the bloodvessels, in different parts of the system, of mi- 
nute whitish granules, bearing more or less resemblance 
to the products of inflammation. 

3. Again, there are certain diseases to which a ten- 
dency seems evidently to be given by a state of general 
Plethora^ depending on full living and deficiency of re- 
gular exercise. This is perhaps more strictly true of 
Gout than of any other inflammatory disease, and of 
Apoplexy, than of any other disease unconnected with 
inflammation. There are others which, if not necessarily 
connected with general plethora, are evidently in a great 
measure dependent on partial plethora, i. e. increased 
flow of blood to, or retarded return from, individual parts 
of the body ; either occurring before they first shew 
themselves, or manifestly facilitating their recurrence. 
Thus all secreting parts, at a time when their secretions 
are peculiarly abundant, are unusually apt to have dis- 
ease excited in them. Indeed it is by producing a state 
of partial plethora that several causes already mentioned, 
and others to be mentioned immediately, as predisposing 



OF THE REMOTE CAUSES OF DISEASE. 



55 



to diseases of individual organs, seem evidently to pro- 
duce that effect. 

A state of partial plethora, although it may be com- 
bined with a weak state of vascular action over the body, 
can seldom be effectually obviated without such evacua- 
tions and low diet as may reduce and keep down the 
whole quantity of blood in the system. 

Those whose knowledge of diseases is chiefly taken 
from examinations after death, as they generally find suf- 
ficient lesions of individual organs to explain the symp- 
toms and event, see little of the evidence which esta- 
blishes the importance of general and local plethora as a 
cause of disease ; but those who are accustomed to trace 
the whole progress of individual cases, and observe the 
effects of remedies and regimen on them, have ample 
grounds for the belief that plethora, general and partial, 
is one of the most frequent, and often the most reme- 
diable, of the causes to which attacks, and still more fre- 
quently recurrences, of various local diseases, whether 
inflammatory, hasmorrhagic, or more chronic, may be 
traced. 

4. A frequent predisposing cause of local disease, 
which may be said to act by causing or facilitating par- 
tial plethora, is Previous Disease, and especially previous 
inflammation, of the same organ, even although it may 
have been at some distance of time, and may have left 
no organic lesion. There is a similar tendency in dis- 
eases primarily seated in the nervous system, to facili- 
tate their own recurrence. This is one of the circum- 
stances by which the seat of the diseased action, that 
may be caused by any accidental excitement, is most 
frequently determined. 

5. Organic disease, or morbid alteration of structure^ 



56 OUTLINES or PATHOLOGY AND PRACTICE. 



already existing in the body, altliough in an inert state, 
and causing little uneasiness, very often acts as an im- 
portant predisposing cause of otlier diseases, whicli might 
otherwise have been avoided ; and that in three distinct 
ways. 

First, The existence of certain organic diseases, pro- 
bably by reason of the quantity of blood directed upon 
them, and the consequent deficiency of the supply of 
blood to other parts of the body, appears frequently to 
dispose the whole system, in like manner as other debi- 
litating causes, to suffer from the application of cold, 
contagion, or other causes of acute disease, more readily 
than it otherwise might have done. It is probably on 
the same principle that pregnancy and lactation render 
the body peculiarly liable to the acute diseases resulting 
from such causes. This holds especially of such organic 
diseases as are rapidly increasing in size, and certainly 
does not hold of all organic diseases. Those which are 
attended with a continual febrile or excited state of the 
circulation [i. e. Phthisis), appear rather to fortify the 
body against the attacks, at least of contagious diseases, 
than to predispose to them. 

Secondly, Organic diseases already existing in the 
body, by confining the circulation in the parts that are 
still healthy, and often by obstructing the circulation, 
first in their own neighbourhood, and afterwards in more 
distant parts, naturally and materially favour local con- 
gestions of blood ; thereby disordering the functions of 
parts not themselves organically diseased, and frequently 
leading either to inflammations, serous effusions, or fresh 
solid deposits from the blood, according to the texture 
and vital properties of the organs where this local j^le- 
thora is established ; in the production or renewal of all 



OF THE REMOTE CAUSES OF DISEASE. 



57 



which secondary affections, however, external exciting 
causes may very often be observed to operate. 

This is especially observed in tracing the consequences 
of organic disease primarily seated in the heart, lungs, 
or liver ; and those who are aware of the predisposition 
to disease of other parts, given by such organic lesions, 
may often, by proper regimen and remedies, prevent the 
application, or even avert the effects, of those exciting 
causes to which such consequences are often immediately 
owing. 

Thirdly, Certain kinds of organic disease (such, e, g. 
as scrofulous tubercles, or tumours composed of the " en- 
cephaloid matter)," already existing in the body, give a 
peculiar tendency to the reproduction of the same kind 
of morbid texture in any part of the body, where disease 
may be excited ; the cause of which tendency will be 
afterwards discussed. 

II. It is especially on those who are predisposed to 
disease, either generally or more partially, in some of 
the ways now mentioned, that the different Exciting 
Causes of disease act with full effect. 

There are many cases, however, in which diseases are 
gradually formed in the human body, under the influence 
of the predisposing causes above stated, without any ex- 
citing cause being observed to operate. And there is 
hardly any exciting cause of disease that acts with uni- 
formity or absolute certainty, even on constitutions ap- 
parently predisposed. 

There is obviously an essential distinction between 
those exciting causes of disease which consist in the ap- 
plication, under peculiar circumstances, to the human 
body, of agents to luhich it is often and necessarily exposed 



58 OUTLINES OF PATHOLOGY AND PRACTICE. 



in all parts of the world, and those which result from 
the application of peculiar poisons^ of local and tempo- 
rary existence only. And it is of the more importance 
to attend to this, because there is an equally important 
distinction as to the kinds of diseased action which are 
found to be excited in the body by causes of these differ- 
ent kinds. 

This is the same distinction as is drawn by statistical 
writers between sporadic diseases, and plagues or epide- 
mics. 

1. The following are the chief agents referable to the 
first of these heads, and which are found to act as ex- 
citing causes of disease ; many of which need only be 
started, in order that the means of avoiding them may 
become obvious. 

a. Mechanical Injury, or chemical irritation, which, 
in a certain degree of intensity, infallibly excite inflam- 
mation, and when acting in co-operation with some of 
the predisposing causes above stated, excite either in- 
flammation of a peculiar character, such as the gouty 
or the scrofulous ; or else, if their application be long 
continued, some kind of chronic organic disease. 

6. Muscular Exertion, hurrying the movement of the 
blood, and often more particularly disordering it, by 
reason of such efforts of straining, affecting the respira- 
tory motions, as impede the return of the venous blood, 
especially from the head, and so favour local plethora. 

c. Mental Emotion, or acute Sensation, sometimes 
suddenly affecting the actions of the heart, sometimes 
augmenting the flow of blood to the head, and some- 
times more gradually modifying secretions, especially 
those of the alimentary canal. 

d. Such Excess, or intemperance in eating or drink- 



OF THE EEMOTE CAUSES OF DISEASE. 59 

ing, as may either injure tlie secretions of the stomach 
and bowels, or so stimulate the circulation, as to deter- 
mine local congestions of blood in any part that may 
be predisposed to that state. 

e. The sudden Suppression of accustomed evacua- 
tions, tending to a state of plethora, which will espe- 
cially affect any organ that may be predisposed. 

f. Such an amount of Evacuation from the body, as 
may suddenly depress the heart's action, or materially 
influence the functions of the Nervous System. 

g. External Heat, in such a degree, as either to irritate 
the part to which it is directly applied, or to impress 
the nervous system violently, or to stimulate the general 
circulation and favour local congestions. 

Ifi. External Cold, applied in such circumstances as 
powerfully to affect the Nervous System, or to disorder 
the circulation. 

In regard to this last, which is the most frequent 
and powerful of this kind of exciting causes, it is to be 
observed, that Cold seldom acts as more than a predis- 
posing cause of disease on the external parts directly ex- 
posed to it ; any diseased action which these parts assume 
being in general directly excited by the subsequent res- 
toration of temperature. It is in internal parts^ the 
temperature of which is probably hardly affected, that 
cold is most apt directly to excite disease. 

The Sensation of Cold which is excited appears, ac- 
cording to physiological principles, to be the connecting 
link between the cause applied externally^ and the mor- 
bid action which it may excite in the interior of the 
body j and the more acute, and more lasting, that this 
sensation is, the greater will be the effects resulting 
from it. 



60 OUTLINES OF PATHOLOGY AND PRACTICE. 



To this simple principle we can refer many facts, 
which are important to be known, as to the agency of 
Cold in exciting disease. 

It seems to be established in Physiology, that the de- 
gree of effect produced on Sensation, or on other vital 
actions, in the healthy state, of either Heat or Cold, is 
by any given degree proportioned, not so much to the 
actual temperature that is applied, as to the amount and 
rapidity of change of temperature, effected by its appli- 
cation ; and the same holds of the morbific effects of 
these agents. Thus the natural temperature of the body, 
applied suddenly to a part previously long chilled by 
frost, produces just the same local effects as the tempe- 
rature of 212°, on a part not previously cooled. 

In like manner, the effect of cold in producing internal 
disease is increased by previously heating the body, and 
still more remarkably by all the other circumstances 
stated above as weakening the circulation ; because, when 
the body is under the influence of these causes, the lost 
heat is slowly and imperfectly restored, and the sensation 
heightened and prolonged. It is greater, for the same 
reason, when the cold is applied by a draft or a current 
of air, or by wet clothes, which rapidly carry off the heat 
of the body ; and it is greater when the cold is applied 
to the extremities, as the parts where the circulation is 
most languid. But in the circumstance of moisture, and 
perhaps in other occasional qualities of cold air, there 
seems to be a peculiarity not yet understood, as to the 
power of exciting inflammation. 

It is probably owing chiefly to a languid state of the 
circulation during Sleep, and consequent deficient power 
of generating heat on the surface of the body, increasing 
and prolonging the sensation of cold applied at that time, 



OF THE REMOTE CAUSES OF DISEASE. 



61 



that the system is then peculiarly apt to suffer from the 
application of cold. 

On the other hand, the injurious effect of cold is les- 
sened or prevented by such a vigorous state of the circu- 
lation as counteracts its effect on the temperature of the 
surface, or quickly restores the temperature that is lost, 
— therefore, by exercise, taken after the cold is applied, 
and by febrile excitement of the circulation, at least by 
such febrile heat as is attended with full strong pulse and 
dry skin ; it is lessened remarkably by such intense oc- 
cupation of mind, as limits the intensity and duration of 
the sensation resulting from it ; and it is lessened by 
such habitual exposure to variations of temperature, as 
blunts somewhat the sensibility of the surface, and ex- 
cites and strengthens the capillary circulation there, ac- 
cording to principles known in Physiology. 

2. Of those exciting causes of disease, which act, 
often with extreme virulence, and on great numbers of 
the human race, but only at certain times and at cer- 
tain places, we may first notice those which are ascer- 
tained to consist in the introduction, by the primce vice, 
of substances acting as poisons on the system, although 
so slowly, that their effects are usually ranked among 
diseases, not as examples of poisoning. The prevention 
of these diseases, by avoiding the introduction of these 
substances into the system, is therefore regarded as 
matter of certainty. 

Thus, the symptoms of Scurvy, depending on a pecu- 
liar alteration of the blood, are ascertained to proceed 
from the long- continued use of innutritions, and espe- 
cially of salted, aliments ; a peculiar form of external 



62 OUTLINES OF PATHOLOGY AND PEACTICE. 



inflammation, tending rapidly to Gangrene, has been 
distinctlv traced to tlie use of wlieat or rye infected with 
the parasitical plant called the Ergot ; it has lately 
been ascertained, that somewhat similar affections, which 
have been endemic in some parts of Germany, depend 
on some of the ingi'edients used in making cheese and 
sausages, which are there common articles of diet ; a 
peculiar variety of Colic, and such an alteration of the 
nutrition of muscles as produces a certain fonn of Palsy, 
are the well known effects of the poison of lead slowly 
introduced into the body; certain yarieties of inflam- 
mation of the skin are produced by some yegetables, 
and by some species of fish, acting as poisons; and 
that peculiar form of mental derangement to which we 
giye the name of Delirium Tremens, is an effect pro- 
duced, on certain constitutions, and in certain circum- 
stances, by alcohol preyiously introduced, in frequent 
doses and at short interyals, into the blood. 

It is important to obserye, that in all these cases, the 
efficacy of the alleged exciting causes is ascertained, 
not by the affection of all who are exposed to them (for 
none of them act with imerring certainty), but by the 
affection of a certain number only of those persons, and 
by the immimity of all who are certainly known to 
ayoid them. 

There are more topical diseases known to be endemic 
in certain localities (i. e. to prevail pretty uniformly 
and exclusively in these), which are also generally be- 
lieved to depend on certain substances taken into the 
body, and operating injuriously on certain organs or 
textiu'es, although their nature, and the mode of their 
introduction, have not yet been so clearly detected, e, g. 



OF THE REMOTE CAUSES OF DISEASE. 



63 



the Bronchocele, in some liilly countries, or on the 
banks of certain rivers, the Cretinism of the Alps, the 
Guinea-worm of some parts of Africa and India, the 
Elephantiasis of Egypt, the Pellagra of Lombardy, 
&c. 

Ao-ain, there are other diseases of much oTeater im- 
portance, because, at certain times, much more generally 
and fatally prevalent, which we ascribe with equal con- 
fidence to the operation of certain Specific Poisons ; al- 
though these are imperceptible to our senses, and known 
to us only by their efii'ects on the human body i and al- 
though the mode of their introduction into the body (by 
the absorbent surface of the lungs) is only matter of 
presumption, not of actual observation. These poisons 
are distinguished by the name of morhific, because their 
eflPects are well marked diseases, i. e. successions of mor- 
bid changes, not imiformly succeeding them, beginning 
some time after they are applied, and going on long- 
after their application is over. 

These are the diseases which prevail epidemimlh/, i. e. 
in certain districts or coinitries, and at certain times 
only, while other coimtries, and the same at other times, 
are quite free from them. 

The mere fact of a disease (clearly distinguished from 
all others) being absolutely unknown for a great length of 
time, in any large community, and prevailing extensive- 
ly in another in a similar climate, or in the same com- 
mimity at another time, is enough to shew that it has a 
local and temporary cause : and that all reference of 
its origin to such exciting causes only as were treated 
under the last head (and which must inevitably be ap- 
plied to many persons in a very large community, even 



64 



OUTLINES OF PATHOLOGY AND PRACTICE. 



within a limited period of time), must be totally una- 
vailing. 

Such a disease may always be suspected to proceed 
from a Poison somehow introduced into the body, and 
experience teaches us, that the origin of that poison is 
generally to be looked for in one of two sources, — either 
in certain effluvia apparently arising from the earth, or 
in exhalations from the bodies of persons previously 
affected with the same diseases ; i. e, that these diseases 
usually arise either from a Malaria or a Contagion, 

At the same time it must be allowed, that there are 
diseases which occasionally prevail much more exten- 
sively than usual, and take nearly the form of epide- 
mics, but do not appear, from the mode of their exten- 
sion, either to be confined to limited districts, or to be 
propagated solely or chiefly by contagion. Of this we 
have examples, in certain seasons, in Erysipelas and 
in Dysentery, and, according to the opinion of many, in 
epidemic Cholera. It appears well ascertained that all 
these shew a certain degree of contagious property, but 
their extension does not appear to be exclusively owing 
to this property. It is commonly referred to the rather 
vague principle of peculiar constitutions of the atmo- 
sphere ; but it is very doubtful whether this term be 
correctly applied. 

The following are the facts observed as to the exten- 
sion of an epidemic disease, which lead us to believe 
that it arises from a Malaria, or emanation from certain 
portions of the earth's surface. 

1. Such a disease is found to prevail within certain 
limits only, all persons who avoid these localities 
escaping the disease, although in all other respects simi- 
larly circumstanced to those who become affected. 



OF THE REMOTE CAUSES OF DISEASE. 65 

2. The districts infected with such a disease are, in 
some respects at least, similar to one another, in the 
different parts of the world where they are found. 

3. No precautions for the separation of the sick from 
the healthy, within these districts, appear to have any 
effect in limiting the extension of the disease ; but the 
removal of the inhabitants, both sick and healthy, to 
other districts, appears obviously to arrest, in a great 
measure, the extension of the disease among them ; 
and is unattended with any injury to the health of those 
with whom they are associated after their removal. 

It is by facts of this kind that we are assured, that 
some kind of subtile matter arising from certain parts 
of the earth's surface, especially from parts of it on 
which water has stagnated, and from which it has gra- 
dually evaporated, is the cause of Intermitting and Re- 
mitting Fevers ; which vary remarkably in different 
seasons and climates, and at different elevations above 
the level of the sea, but still retain the same general 
characters. 

It does not appear, on careful inquiry, at least in 
Scotland or Ireland, that there is any evidence of this 
description to shew that the Continued Fever of this 
climate can be produced by a Malaria ; and the effect of 
putrid effluvia, and bad draining and ventilation, in 
favouring the diffusion of that disease, is easily explained 
by the depressing effect, already noticed, of vitiated air 
on the human system, by the other circumstances of the 
inhabitants of such places, and by the concentration of 
contagion necessarily occurring in such situations. 

Whether the putrefaction of animal and vegetable 
matter is a condition essential to the generation of this 
Malaria, or what other conditions are really necessary, 

E 



66 



OUTLINES OF PATHOLOGY AND PRACTICE. 



is mucli more doubtful ; but it is certain that the con- 
ditions which are essential, belong to the localities which 
are thus affected, not to their inhabitants ; and it will 
afterwards appear that the laws of its development and 
diffusion are to a certain degree ascertained ; that its 
development may be in a great measure prevented by 
certain means, particularly draining and cultivation ; and 
that its effects may be frequently avoided by availing 
ourselves of certain peculiarities in its diffusion, g, its 
being absorbed by water, attaching itself to trees, being 
dissipated by the heat of the sun, and diminishing in 
virulence at a certain elevation above the level of the 
sea. 

Again, the following facts, when carefully observed, 
as to the mode of extension of other epidemic diseases, 
especially if observed about the time of their commence- 
ment, when they are not yet generally diffused, leave 
no room for doubt, that they propagate themselves by 
Contagion, or in consequence of exhalations or secre- 
tions from the bodies of persons already affected with 
them, being somehow introduced into the bodies of those 
who become affected in their turn. 

1. Successions of cases, of the diseases in question, 
are observed within narrow limits, both of space and 
time ; first in one situation, aud afterwards in others ; 
while other districts, similarly circumstanced, and fully 
inhabited, are wholly unaffected. 

2. On inquiring into the circumstances of these suc- 
cessions of cases, we find them, although, for reasons 
already given, most apt to occur in certain places, yet 
by no means confined to one description of locality; and 
occurring in situations which vary irregularly with the 



OF THE REMOTE CAUSES OF DISEASE. 67 



different returns of the disease, instead of remaining 
nearly fixed, as is the case in regard to malarious dis- 
tricts. 

3. There is very frequently, in such cases, evidence 
of importation into the affected districts, i, e. the first 
patient in the succession is found to have had inter- 
course with persons who have had the same disease, or 
recently recovered from the same disease elsewhere ; — 
either directly, or through the intervention of substances, 
to which exhalations from sick persons may easily at- 
tach themselves. 

4. Within the district where the disease exists, those 
persons who have earliest and closest intercourse with 
the sick, are observed to be first and chiefly affected. 

5. Absolute seclusion from all intercourse with the 
persons or houses affected, produces complete immunity 
to whole families, to the inmates of barracks, schools, 
workhouses, or hospitals, even in the midst of the in- 
fected districts. 

6. When the sick are carefully separated from the 
healthy in the beginning of the disease, and all sub- 
stances, to which exhalations arising from them can 
have attached themselves, are purified, the extension of 
the disease, even within the infected districts, is ob- 
viously diminished, or even entirely stopped. 

Observations of these different classes are so many 
different ways of establishing the general propositions, 
— 1 . That those who are known to have had intercourse 
with the sick, are affected with one of these diseases in 
a proportion very much greater than others ; and, 2. That 
no other common circumstance, but that of intercourse 
with the sick, can be ascertained to exist in the case of 
most of the persons who are affected, and not to exist in 



68 OUTLINES OF PATHOLOGY AND PRACTICE. 



the case of tlie mucli greater number who escape. And 
when these propositions are established, especially in 
the case of a disease which has recently invaded a large 
community, and affected only a small portion thereof, 
a calculation of chances puts beyond all doubt the effi- 
cacy of the circumstance of intercourse with the sick, 
in determining the attacks of the disease ; and shews, 
that all other means of preyention, as to those diseases, 
must be held as subordinate to the grand object of pre- 
venting such intercourse. 

All other considerations are perfectly irrelevant as to 
the question of the contagious nature of a disease, but 
those which bear on the evidence of the propositions 
stated above. For example, the escape of great nimi- 
bers of those w^ho have intercourse with the sick, is no 
evidence of the disease not beino- contaoious. if it be 
ascertained, — ^1. That the disease is one of local and 
temporary existence only; and, 2. That of those known 
to have had intercourse with the sick, the proportion 
who take the disease is very much greater than that of 
those in whose cases such intercourse cannot be traced. 
These points being ascertained, the escape of numbers, 
who have intercourse with the sick, becomes only evi- 
dence of what was formerly observed, that this and all 
other, strictly morhific poisons, take effect only on cer- 
tain constitutions. 

It is on evidence of the kind above stated, that we 
ascribe more or less of a contagious property to various 
febrile diseases, — the Continued Fever of this climate, 
and probably a continued fever occasionally prevailing 
in hot climates, — Small-pox, Chicken-pox, Measles, 
Scarlatina, Plague, Erysipelas, Dysentery, Influenza ; 
and the same evidence will be found to extend to the epi- 



OF THE EEMOTE CAUSES OF DISEASE. 



69 



demic Cholera altliougli tliere are certainly anomalies 
as to the propagation, as well as the symptoms, of that 
singular disease. 

It is by similar evidence that we are assured of the 
contagious property of scabies, syphilis, gonorrhoea, and 
purulent ophthalmia. The accuracy of the conclusion 
is confirmed in the case of several of the febrile dis- 
eases, as well as of those chronic diseases, by the effect 
of inoculation. The very peculiar contagious poison by 
which hydrophobia is excited, has never been observed 
to be communicated otherwise than by inoculation. 

But in ascribing a contagious property to a disease, 
we must be careful not to consider it as ascertained, 
that contagion is its only exciting cause. There is good 
reason to believe, that several of the diseases now men- 
tioned originate occasionally, at the present day, from 
unknown causes, and perhaps extend themselves in an 
unknown way, besides being propagated by contagion ; 
and it is still doubtful whether the remittent fevers, ori- 
ginating in malaria, may not occasionally, and under 
certain circumstances, spread by contagion. 

Some special facts, that have been ascertained in re- 
gard to malaria and contagion, will be more properly 
stated as part of the history of the diseases which they 
excite ; but it is important to state here some general 
laws in regard to the whole of this class of the exciting 
causes of disease, several of which have an obvious 
practical application, as suggesting means of prevention, 
or indeed are made known only by the ascertained effi- 
cacy of 'such means. The knowledge of all these laws 

* See Dr Simpson's paper on the Cholera in Scotland. — Edin- 
burgh Medical and Surgical Journal, vol. xlix. 



70 OUTLINES OF PATHOLOGY AND PEACTICE. 



is necessary, in order to enable us to form a sound judg- 
ment, and to correct partial and erroneous views, of 
tlie efficacy of any particular means of prevention wliicli 
may be recommended. 

1. It is a well-ascertained fact, tbat the morbific effect 
of these poisons is remarkably increased by debility 
and inanition, and diminished by fulness and excite- 
ment, of the vascular system ; and this gives good rea- 
son to believe that their action is consequent on their 
absorption into the blood ; because it is known in Phy- 
siology, that by these circumstances absorption is re- 
markably increased and diminished.* 

2. None of them act with uniformity, epidemic 
fevers of all kinds, and all contagious diseases, varying 
extremely in character, in prevalence, and in malignity, 
at different times, and for reasons which are very im- 
perfectly known. 

This difference is evidently in part owing to the con- 
currence, or absence, of some of the predisposing causes 
of disease above stated, especially of impure air, imper- 
fect nourishment, and mental depression, long-continued 
heat or cold ; but there are many examples of such dif- 
ference in the extension, and in the character of diffe- 
rent epidemics, or of the same at different periods of 
its progress, which we can ascribe only to variations in 
the nature and virulence of the morbific poisons them- 
selves. 

3. None of them act with unerring certainty ; some 
persons escaping, even when such diseases are most pre- 
valent and malignant, and in circumstances in which 
the greatest number suffer. 



* See Physiology, p. 67. 



OF THE REMOTE CAUSES OF DISEASE. 71 

4. Both malaria and contagion are very often aided 
in their effect, not only by predisposing causes, pre- 
paring the body for their reception, but by exciting- 
causes, concurring with them, and determining attacks 
of disease, which might probably otherwise have been 
avoided. Thus during an epidemic fever, so many at- 
tacks immediately succeed exposure to cold, that many 
pathologists have thought this a sufficient exciting cause 
of that disease; and in the malarious countries, so 
many agues are contracted apparently by exposure to 
cold, or intemperance, that some have represented the 
malaria as the predisponentj and cold or disordered sto- 
mach as the common excitino- cause of aoue. In like 
manner, scurvy, although the specific effect of salted 
aliments, is very generally observed to be essentially 
aided and promoted by cold, by intemperance, and by 
mental depression. 

It is probably to the frequent concurrence of other 
exciting causes with malaria or contagion, in producing 
epidemic fevers, that we should ascribe the remarkable 

I fact, that when such epidemics are most prevalent, most 
other diseases nearly disappear ; the poison already 
imbibed into the human system, determining the excita- 
tion of its own peculiar effect, on the application of any 
one of the common exciting causes of disease, rather 

i than of the other diseases, which at other times might 
result from that application. 

It appears, therefore, that the agency of what are 
strictly called morbific poisons, differs from the agency 
of what are more commonly called poisons, in being 
much more dependent on contingencies, both pre- 
vious and subsequent to their introduction into the 
body ; and this fact, which could not have been antici- 



72 



OUTLINES OF PATHOLOGY AND PRACTICE. 



pated d priori, but seems well ascertained, enables ns to 
understand that in certain cases, even after tbe diseases 
resulting from these agents have shewn themselves, they 
may be not only conducted to a favourable termination, 
but successfully arrested in their course. 

5. In all the febrile diseases which are of local and 
temporary existence, and result from the operation of 
these poisons, there may be observed, at least when they 
appear in their most virulent form, a peculiarity of symp- 
toms, and a kind of danger, hardly to be dreaded in 
diseases excited only by such causes as are of more ge- 
neral and permanent existence. This peculiarity may 
be said to consist in a general depression of vital action, 
and peculiarly of the functions of the Nervous System, 
with an alteration of the vital properties of the blood, 
and is denoted by the appearance of more or less of the 
symptoms, which have the name of typhoid. 

6. In regard to all these diseases, consequent on the 
introduction of Specific Poisons into the system, this 
remarkable fact may be observed, that the tendency to 
them is remarkably altered by their being once excited. 
The Intermittent Fever, from malaria, is more easily 
excited, after having once existed, but in a somewhat 
milder form ; and its most malignant form seldom at- 
tacks any individual twice. All the diseases result- 
ing from specific contagions (if we except Erysipelas) 
are less easily excited when they have once been suffered; 
and in the case of the Contagious Exanthemata, this di- 
minution of disposition to the disease goes almost the 
length of absolute immunity. In the case of small- 
pox, it has been now completely ascertained, that the 
contagious poison undergoes a change, by being trans- 
mitted through the bod^^ of another animal, whereby 



OF THE REMOTE CAUSES OF DISEASE. 



73 



the disease is rendered infinitely milder (taking the 
form of cow-pox) in the human subject ; and that this 
mild form of the disease gives security to most persons 
against the virulent form ; and when it does not give 
complete protection, mitigates any subsequent attack so 
generally and so decidedly, as to afford the most effec* 
tual antidote to disease of which we have any example 
in Medicine. 



( U ) 



CHAPTER IV. 

OF THE ACTION OF EEMEDIES IN GENEKAL, AND THE 
EVIDENCE OF THEIR EFFICACY. 

It seems important to premise some general observa- 
tions on the clifficnlty of jndging of the real inflnence of 
remedies over diseases, and on the proper means of sur- 
mounting those difficulties, before giving a general sketch 
of the resources of medical practice. 

Several causes may be pointed out as very frequently 
misleading us in our estimate of the power of remedies 
over disease. 

1. The natural tendency of most kinds of diseased 
action to spontaneous abatement, to which the action of 
almost all remedies is subservient, but which is very 
frequently mistaken for the effects of remedies used. 

2. The unobserved action of other circumstances in 
the situation of patients, besides the use of any remedy 
of which the value is attempted to be established, e, g, oi 
the antiphlogistic regimen, when depleting remedies are 
used, or of change of season or of situation, when tonic 
remedies are used. 

3. The extreme diversity of cases to which the same 
name, and even the same pathological description is 
correctly applied, as to extent, or intensity, or malignity, 
and therefore as to the result to be expected, even when 
no remedies are used. 



OF THE ACTION OF REMEDIES IN GENERAL. 



75 



4. The diversity of constitutions, in wMcli the same 
kind of diseased action may be excited, and the difference 
of result thence to be anticipated, under any practice that 
may be employed. 

These peculiarities attending the observation of the 
effects of remedies necessarily vary the conditions of 
each individual case, in which such observations are 
made, and make it impossible for us to vary them arti- 
ficially, so as to have a complete experimentmn crucis 
as to the effect of any remedy. They not only vitiate 
many inferences as to the good effects of alleged reme- 
dies, but often blind us to the injurious effects which 
they may produce in the course of diseases. The same 
difficulties do not attend the observation of the effects of 
remedies intended only for the attainment of one great 
object of medical practice, — palliating symptoms in cases 
which are regarded as hopeless ; but even in these cases 
it is often very difficult to judge how far temporary al- 
leviation is purchased at the cost of subsequent aggrava- 
tion. 

While these circumstances greatly embarrass all con- 
clusions that can be drawn as to the efficacy of remedies, 
it is also to be remembered, that certain obvious moral 
causes naturally lead most men, in cases of doubt, to ex- 
aggerate, rather than undervalue, the importance of their 
own interference with the natural course of diseases. 

The means which naturally suggest themselves as fit- 
ted for guiding our judgment under these difficulties, as 
to the safety and utility of remedies, and which have 
been adopted with more or less success in all ages, are 
the following : — 

1. We multiply as much as possible the observations 
of individual cases to which any particular remedy is 



76 OUTLINES OF PATHOLOGY AND PRACTICE. 



applied, rioting as carefully as possible all tlie varying 
circumstances of these cases, so as to obtain statistical 
evidence as to tlie efficacy of the remedy, and the in- 
fluence of other causes simultaneously applied, too ex- 
tensive to be vitiated by accidental contingencies. 

If all alleged remedies had been specifics^ i. e. sup- 
posed to exert a direct power over diseased actions, not 
referable to any more general principle, or if the same 
disease had followed the same course in all persons, we 
could have obtained statistical information as to their 
efficacy in this way, equally certain as the statistical evi- 
dence we have of the power of the exciting causes of any 
disease ; but when it is considered that the great majority 
of remedies have certainly no specific power, and that 
their action is believed to be only subservient and auxiliary 
to the pro\4sions of nature for the spontaneous decline of 
diseases, and to be dependent on the influence which they 
exert over the functions of the body in health ; that 
they are useful, therefore, only in certain periods and 
circumstances of the diseases to which they are appli- 
cable ; and that the natural course of these diseases is 
exceedingly various, and liable to alteration, as already 
observed, by difi'erent causes, both internal and external 
to the body, many of which are extremely obscure, and 
beyond our controul ; — we can easily perceive that the 
application of statistics to the influence of these remedies 
on disease, must be liable to great ambiguity ; and that 
the application of other species of evidence, for practi- 
cal purposes, is really necessary. 

2. We, therefore, watch the progress of the symp- 
toms, after the application of the remedy, in individual 
cases, and observe whether there is such alteration in 
these, when compared with the usual progress of the 



OF THE ACTION OF REMEDIES IN GENERAL. 77 



disease, as gives us reason to believe that the natural 
process for the restoration of health is promoted. 

3. But again, adverting to the statements already 
made, as to the great variety in the extent and intensity, 
and natural progress, of different cases which are re- 
ferred to the same place in the nosology, we can easily 
perceive, that the mere observation of external symptoms, 
without reference to the real nature of the internal 
changes producing them, will not sufficiently inform us 
how far the remedies used really exert a beneficial effect 
on morbid changes. We find it necessary, therefore, 
not with the view of applying reasoning d priori, but in 
the view of availing ourselves of all the facts known by 
experience v/hich illustrate the subject, to inquire into 
the intimate nature, or pathology, of the diseases thus 
treated, and endeavour to ascertain whether the changes 
actually going on within the living body, are such as it 
is reasonable to think that the remedy in question can 
directly or indirectly modify or controul. 

4. This makes it necessary to inquire farther into the 
real nature of the change which that remedy can effect 
on the body, i. e. as to its mode of operation, which ne- 
cessarily requires our inquiring into what has been 
called its " physiological action," or the mode in which 
it affects the healthy body; from the knowledge of which, 
compared, with our knowledge of morbid actions them- 
selves, we can frequently draw an inference, with more 
or less confidence, as to its real efficacy in averting 
morbid changes, or promoting their favourable termina- 
tion. 

Being thus led to see the importance of scientific or 
theoretical knowledge, in regard to the real action of 
remedies on the living body, we observe, that almost all 



78 



OUTLINES OF PATHOLOGY AND PEACTICE. 



those Oil which we can place any reliance in practice, are 
referable, according to what we believe to be the mode of 
their action, to one or other of the following classes. 

In a very few instances only, we can ascribe to cer- 
tain remedies a specific power, known only by experi- 
ence, and apparently unconnected with any sensible 
effect, of counteracting certain morbid actions, and so 
preventing their injurious effects. The best example is 
the power of Cinchona, or its alkaloid, Quinine, over In- 
termittent Fevers. The effect of certain remedies, 
usually called Alteratives, on the results of certain spe- 
cific inflammations ; of Mercury on Syphilitic inflamma- 
tion, and its consequences, and, as many believe, on va- 
rious other inflammations j of Sulphur on Scabies ; of 
Colchicum on rheumatic or gouty inflammation ; of 
Iodine, or Sarsaparilla, and other vegetables, on certain 
forms of inflammation in the periosteum and skin ; al- 
though less powerful, may likewise be called specific in 
the present state of our knowledge ; although it may be 
inferred with probability, that the action of some of these 
remedies may be referred to other heads presently to be 
mentioned. 

The beneficial action of all other remedies, besides 
these specifics, in diseases which admit of cure, is only 
auxiliary to the provisions of nature for the spontaneous 
cure of diseases ; although incapable of arresting the 
course of morbid actions, they can frequently modify 
them, and counteract those changes which, in the cir- 
cumstances of individual cases of disease, are most im- 
mediately dangerous. We can have no doubt, that in 
this way they frequently save life, and generally, when 
prudently used, place the body in circumstances more 
favourable to the spontaneous decline of diseases. This 



OF THE ACTION OP REMEDIES IN GENERAL. 79 



is done by an influence on the body during tbe diseased 
states, wbieb we tbink capable of explanation by what 
we know of tbe operation of these agents on the healthy 
body. 

Of these we may make an arrangement according as 
they act, as far as we can judge, primarily and chiefly, 
1. On the fundamental function of Circulation; 2. On 
the Secretions and Excretions ; 3. On the Nutrition, 
particularly of those parts which are themselves the 
product of disease ; 4. On the composition and qualities 
of the blood ; 5. On the functions of the Nervous Sy- 
stem. 

I. The following are the means we possess of directly 
influencing the actions of the heart, and the flow of 
blood through all parts of the body at once. Some of 
these act by being taken into the blood and circulat- 
ing with it through the body ; others seem to produce 
their effect by making certain impressions on the Ner- 
vous S^^stem, whereby, as various facts in Physiology 
instruct us, the actions of the heart and the flow of blood 
through the smaller vessels may be influenced. 

1. Stimulants, either taken into the circulation, as 
wine, alkohol, ammonia, or applied in various ways to 
the sensitive parts of the Nervous System, as external 
heat, various irritating applications to the surface of the 
body, and especially such as excite the respiratory 
muscles, and thereby cause the arterialization of an in- 
creased quantity of blood ; all which excite and invigo- 
rate for a time the action of the heart, and are therefore 
often of essential service in those circumstances of very 
various diseases (both acute and chronic), in which death 
is threatened simply by Asthenia. The effect of these is 



80 OUTLINES OF PATHOLOGY AND PRACTICE. 



always transient, and very often followed by more or 
less of depression, partly to be ascribed to the mere cir- 
cumstance of increased action, but cbiefly to be regarded 
as an ulterior, altliouo-li variable, effect of stimulatino- 
medicines themselves, such as alkohol or aether. 

It is generally thought that the stimulating effect of 
wine is less transient, and followed by less depression, 
than of other substances of this class, and that bv odving 
it in small and frequently repeated doses during acute 
diseases attended with much debility, any injurious de- 
pressing effect may be avoided until the period of these 
diseases is over. 

The most powerful of all strictly stimulant remedies, 
imfortunately applicable in a few cases only, is the trans- 
fusion of blood into the veins ; and along with it we may 
include, from what has been seen in some cases of ma- 
lignant Cholera, the saline injections into the veins. 

2. Tonics, which are thought to act in like manner, 
some directly, others through the medium of the Ner- 
vous System on the heart's actions and the circulation 
generally, with less activity, but with more permanent 
exciting effect, and which are, of course, chiefly appli- 
cable to the case of chronic diseases, or to the last stao-es 
of the acute. 

There is no doubt of the effect of a Tonic Regimen, — ■ 
of nourishing diet^ active exercise^ free exposure to 
ah% the regulated application of cold^ and mental interest 
and excitement, — on the circulation, and all its sub- 
ordinate functions ; nor of the value of these expe- 
dients alone, or in combination with other remedies, 
demanded on other accounts, in the treatment of many 
diseases. The most important and most permanent 
effect of such expedients, however, is certainly in part, 

8 



OF THE ACTION OF REMEDIES IN GENERAL. 81 



and we have not tlie means of judging liow far, referable 
to an alteration and improvement of tlie state of the 
vital affinities existing in the living body, and not merely 
to any increase of the contractile power of its moving- 
parts. The influence of any medicines specifically to 
strengthen the general circulation, has been doubted ; 
and the doubt is sufficient to shew, that the efficacy of 
any medicines of this class is but slight ; but various 
local applications, stimulant and astringent, have a cer- 
tain degree of strengthening effect on the circulation at 
the parts to which they are applied. 

3. The opposite, depressing, or sedative effect on the 
circulation, is exerted by certain medicines, chiefly of the 
nauseating kind, as by Tartar Emetic, Digitalis, and 
Colchicum. It is still doubtful whether these possess 
any peculiar sedative or antiphlogistic effect distinguish- 
able from that depressing influence which always attends 
nausea ; but it is certain, that, in certain circumstances 
of disease, these are a resource of very considerable 
value. A more powerful sedative efl'ect is produced by 
the external application of cold of a certain duration and 
intensity ; and this expedient is in some circumstances, 
both of local and general disease, very useful ; but as its 
effect, within the limits that are safe, is always tran- 
sient, and as caution is necessary to prevent its acting 
as an exciting cause of other diseases, this power is not 
so often usefully employed as a sedative agent as might 
be expected. 

Various local applications have a sedative, cooling, 
soothing, or astringent effect, on the capillary circulation 
of the parts to which they are chiefly applied. 

4. An obvious permanent and important sedative effect 
on the whole system is produced by what is termed the 

F 



82 OUTLINES OF PATHOLOGY AND PRACTICE. 

Antiphlogistic Regimen, of which the essential parts are 
Low Diet, Rest, and Quiet ; which is " proper to be em- 
ployed during the greater part of all inflammatory and 
febrile diseases," and frequently in other diseases likewise, 
although with modifications to be afterwards considered. 

5. The most powerful, and therefore most beneficial, 
agent of this description, is Bloodletting, the good effects 
of which may be referred to the following heads : — 

1. It weakens the action of the heart, and therefore 
the force with which the blood is moved in all parts of 
the circulation. 

2. By lessening the whole quantity of the blood, it 
lessens the intensity of diseased actions of various kinds, 
particularly inflammatory action, kept up by the flow of 
blood to individual parts of the body. 

3. It causes a temporary but important derivation of 
blood from other parts, to that whence the blood issues. 

4. It promotes the action of those remedies which in- 
crease the secretions and excretions, or removes a cause 
(viz. fulness of the bloodvessels, and vigorous circulation 
through them) which opposes their operation. 

Experience shews, that the remedy is most important, 
with these intentions, in cases of local diseased action 
(chiefly, but not exclusively, inflammatory) which are 
attended by, and apparently act as the causes of, general 
disturbance and excitement of the circulation, — and in the 
early stages of these, before the disorganization conse- 
quent on these morbid actions has made progress ; and 
that the less complicated the local disease, and the more 
healthy the previous condition of the body, the better the 
prospect of good effect from the remedy ; — that it is less 
effectual when the previous state of the system is not 
vigorous, or the disease complicated ; — and becomes use- 



OF THE ACTION OF REMEDIES IN GENERAL. 83 



less or injurious in the ulterior stages of these diseases, 
when disorganization has been effected ; and again, that 
in diseases of the general system, excited by the morbi- 
fic poisons, although the circulation is much accelerated 
and excited, the greatest danger, in the advanced stages, 
is not dependent on that condition of the circulation ; and 
is in most cases, and in most epidemics, very liable to 
aggravation by such loss of blood in the early stages as 
materially weakens the system. 

II. Of remedies acting chiefly on the Secretions and 
Excretions, the most generally useful are those which 
(although taken into the circulation very generally be- 
fore they affect the system) produce their chief effects 
on the stomach and bowels, i. e, the Emetics and Pur- 
gatives ; and the following may be stated as the benefi- 
cial modes in which they affect the system. 

1. They relieve it of the presence of foreign matters 
(or matters exterior to the circulation, and destined 
only to expulsion from the body), the effect of which, 
primarily on the mucous membrane of the Primse Vise, 
but affecting sympathetically various other parts, is a 
cause of some, and an aggravation of many more, dis- 
eases, both acute and chronic. The Carminatives, the 
Antacids, and Anthelmintics, may be said to be subsi- 
diary means of attaining this object, and to be useful in 
this way. 

2. They diminish, in a considerable degree, the 
quantity of the circulating fluids, — draining off much of 
the serous part of the blood, and probably suspending, 
for a time, the process of assimilation, by which the 
waste of the animal matters of the blood is continually 
supplied,- — and thus they weaken the circulation in all 
parts. 



84 OUTLINES OF PATHOLOGY AND PRACTICE. 



3. They alter materially the distribution of blood in 
the body ; and the purgatives, in particular, have a 
powerful and often very useful effect as derivants, from 
the head and upper parts of the body. 

4. All such medicines increase the flow of the secre- 
ted fluids of the intestines, particularly of the Bile, and 
some of them are believed to have a peculiar power of 
increasing and improving this secretion, and are hence 
called CholagogTies, or more generally, Alteratives. It 
is reasonable to suppose that such a power exists in a 
certain degree, particularly in the preparations of Mer- 
cuiy ; but its extent has certainly, been much exagge- 
rated, and the secretion of the bile, when vitiated, may 
be gradually improved by the continued use, probably of 
any purgatives, in moderate doses. In this way, such 
medicines cause th€ expulsion from the body of matters 
which would otherwise be retained, either in the blood, 
or in the biliary ducts, and would act more or less power- 
fully as poisons. 

5. By diminishing the quantity of the serous part of 
the blood, they certainly stimulate the action of Absorp- 
tion in all parts of the body, especially of any fluid efiii- 
sions. This object is more safely and beneficially at- 
tained by the Purgatives ; and this and other means of 
promoting certain excretions are the most effectual, if 
not the only true, sorbefacients. 

6. They promote the discharge of other excretions, 
e.g. the previous use of purgatives often apparently 
promotes the action of diuretics, and the action of vo- 
miting more remarkably, although temporarily, facili- 
tates that of expectorants and of sudorifics. 

Those beneficial effects are attended, in some instances, 
or even superseded, by certain inconveniences or dan- 



OF THE ACTION OF REMEDIES IN GENERAL. 85 



gers ; thus the altered determination of blood, by the 
act of vomiting, is sometimes injurious in affections of 
the head, and the debilitating effect of repeated purga- 
tives is often injurious, — perhaps especially in diseases 
of the chest. 

The means which we possess of increasing the other 
Excretions from the body, are of more limited applica- 
tion, but in certain cases are of signal efficacy. The 
occurrence of Sweating, in the course of acute diseases, 
is much more frequently a sign than a cause, of abate- 
ment of the morbid action, and when so, is hardly to 
be promoted, and not to be imitated by art ; but in cer- 
tain of the inflammatory diseases, especially of the 
muscles and joints, and of the mucous membranes, it may 
be produced pretty certainly by certain medicines and 
regimen, and may be signally useful ; and the benefit de- 
rived from many medicines, both vegetable and mineral, 
in affections of the skin, and from the various kinds of 
tepid and warm bathing, on many diseases, is certainly 
much connected with, if not wholly dependent on, their 
permanent diaphoretic effect. 

The use of Diuretics is nearly confined to the attain- 
ment of a single object, but one which is often of the 
most essential importance, viz. the consequent increase 
of the absorption of extra- vascular serum in dropsical 
cases. The use of Expectorants is more frequently 
demanded, but the efficacy of the means in our power 
of promoting this excretion, either by the nauseating or 
the more stimulating expectorants, is less decided. The 
use of Errhines and Sialogogues is very limited ; but the 
different expedients which are called Emmenagoguegj 
are not only frequently demanded, but often seem de- 
cidedly effectual. 



86 



OUTLINES OF PATHOLOGY AND PRACTICE. 



Another class of remedies may be said to act by estab- 
lishing new excretions from the body, viz. the Counter 
Irritants, — the effect of some of which is rapid and tran- 
sient, that of others slow and permanent ; both, when 
prudently and judiciously employed, are found to be the 
most useful derivants of the blood from parts where 
certain kinds of diseased action are going on. 

There are means in our power, often essentially use- 
ful, of attaining the very opposite object to that for 
which these evacuant remedies are designed, viz. the 
Astringents, by which (partly, as we believe, by a power 
exerted even on dead animal matter, but chiefly by an 
agency on the living solids, often much aided by opiates) 
excessive evacuations, of blood itself, or of any of the 
excretions, are restrained, and the debility, or threat- 
ening of death by Asthenia thence resulting, in the 
course of various diseases, both acute and chronic, may 
be averted. Caution is required in the use of these, as 
of all other powerful remedies, particularly in the early 
stage of diseases, in which excessive excretions occur, 
lest they should occasion an injurious retention of mat- 
ter destined only to excretion, and more or less of the 
Antiphlogistic treatment, is very often properly pre- 
mised to their use ; but there are many cases of dis- , 
eases, in which astringents are of the highest import- \ 
ance ; and we have a tolerably distinct knowledge of 
the different means of this kind, which are suited to the 
discharges from different parts of the body, e. g, from 
thepungs, from the bowels, the bladder, or uterus. 

III. The remedies which are thought to exert a pe- 
culiar power over the amount and nature of the pro- 
ducts of Nutrition, and particularly over the formation of 



OF THE ACTION OF EEMEDIES IN GENERAL. 87 

morbid growths, are sometimes called Alteratives ; but 
as the chief object of practice, in regard to morbid 
growths, is to restrain their formation, or cause their 
reabsorption, i, e. to excite the action of absorption, 
which always accompanies the vital act of Nutrition in 
animal bodies, they are more strictly called Deobstru- 
ents. But we must admit, that it is much easier, in 
practice, to perceive the circumstances in which these 
remedies are indicated, than to find effectual means of 
fulfilling the indication. 

The important distinction to be kept in mind here is, 
between the morbid growths, which consist only of ma- 
terials naturally existing in the blood, and in the solid 
textures of the body, and those which are heterologous 
deposits, foreign to the healthy condition of the body. 
When swellings consist only of the first kind of matter, 
there is always a strong tendency to their absorption, as 
soon as the morbid action producing them has subsided, 
and the stronger, as the system is the more healthy. 
Such absorption, in these circumstances, is facilitated 
by the proper means of correcting any deviation, of what- 
ever kind, from the healthy state of the body, and often 
especially by what we have described as the Tonic E.e- 
gimen ; and several medicines, e. g. Mercury and Iodine, 
appears certainly to possess a power in promoting this 
action, although of the degree of that power, exerted, 
as it usually is, only in circumstances where Nature 
is already employed in the work of absorption, it is 
very difficult to judge. But when heterologous deposits 
have once occurred, their complete reabsorption is pro- 
bably beyond the reach of any provisions which the liv- 
ing body possesses ; although even then such means as 
are effectual in really invigorating the system, restoring 



88 



OUTLINES OF PATHOLOGY AND PRACTICE. 



tlie more natural condition of the vital affinities existing 
among the constituents of the blood and the animal tex- 
tures, may certainly restrain their farther development, 
and even, as we have good reason to think, determine 
ultimately the reabsorption of a part of their substance. 
Of this we have unequivocal evidence when tubercles 
have been deposited in early life^ when the general health 
has improved, and the vestiges of these tubercles been 
found subsequently, nearly converted into earthy matter. 
But we have no reason to believe that any medicines 
possess any specific power of exciting absorption of such 
matters. 

There are some instances, both in medical and surgi- 
cal practice, where the morbid nutrition of small parts 
of the body may be corrected in a much more effectual 
and summary manner, viz. by destruction of the part in 
which the diseased action is going on, followed by a 
healthy state of nutrition in the neighbouring parts, and 
thereby obliteration of the disease, — as in the healing of 
inveterate ulcers after application of caustic, or the de- 
struction of parts in which the Hospital Gangrene has 
appeared. 

IV. It is almost certain, that no remedies which pro- 
mote absorption can do so by any change they can pro- 
duce in the contractile power of the vessels through 
which the absorption takes place, and we have every 
reason to believe, that it is only by a change in the vital 
attractions and mutual affinities of the constituents of 
the blood and the textures in any part of the body, that 
an increase of the absorption there can be effected. All 
truly deobstruent remedies, therefore, and, indeed, all 
that affect the nutrition and secretions in the body, may 



OF THE ACTION OF REMEDIES IN GENERAL. 



89 



be believed to act primarily, at least in part, on the 
Blood, — not, however, primarily or chiefly on its chemi- 
cal composition, but on its vital properties. 

Eut there are other remedies which are thought to 
exert a peculiar power exclusively on the blood, parti- 
cularly increasing the quantity, or stimulating the vital 
powers, of that portion of the blood which in the living- 
body possesses the properties of Fibrin ; and on the vital 
powers of which portion the very existence of the natu- 
ral circulation in the capillaries appears distinctly, from 
some of the experiments of Magendie, to depend. It is 
thus that we believe fresh vegetable food, and vegetable 
acids, to act in correcting the morbid state of the blood 
in Scurvy ; or animal food to a certain extent in Dia- 
betes ; and it is thus also that different saline substances. 
Ammonia, the Chlorates, &c., are thought by many to 
act (although with a much less certain and less powerful 
influence) on the peculiar condition of the blood in ty- 
phoid fever, and other strictly febrile or exanthematou s 
diseases, in Purpura and malignant Cholera. 

It is obvious that the great desideratum in Therapeu- 
tics at present is, to establish the laws according to 
which the vital affinities of the minute particles of the 
blood and the living solids may be altered by the agency 
of remedies ; and that when this is done, most of the 
remedies which w^e now describe, somewhat vaguely, as 
stimulating secretions, excretions, absorption, &c., or 
even as specifics, will be regarded as acting primarily on 
the blood, and on the vital changes which are continually 
going on in its substance, and which are essential to its 
healthy constitution. 

y. The agency of the last class of remedies which 



90 



OUTLINES OF PATHOLOGY AND PRACTICE. 



we have to notice is better understood, not indeed in 
its own nature, but in tlie effects by wliicb it is made 
manifest, viz. that of tbe remedies which specifically 
affect the Nervous System. Of these the most im- 
portant are the Narcotics, i. e. such doses of different 
narcotic poisons as are found by experience to act only 
as soporifics and anodynes, and which are, from those 
powers, among the most important resources of medi- 
cine. These are always attended with inconveniences, 
and particularly with this, that the quantity of them re- 
quired to be taken to produce the desired effect on the 
nervous system is, by reason of a well-known la.w of 
nervous actions, subject to continual, and, in some in- 
stances, almost indefinite increase ; but in many cases 
of disease — particularly of incurable disease — this in- 
convenience, when weighed against the sufferings which 
such remedies can relieve, does by no means justify the 
discontinuance, or even intermission, of their use. 

Besides the Narcotics, other medicines, such as aether, 
assafoetida, &c,, which make a strong temporary im- 
pression on the Nervous System, have a certain degree 
of efficacy as Antispasmodics ; there are certain means, 
such as Galvanism, and small doses of Nux Vomica, 
which act peculiarly as Stimulants to the Nervous Sys- 
tem ; there are others, commonly called Tonics, such as 
the preparations of bark and steel, and other metallic 
preparations, which have in many instances a remark- 
able effect in diminishing the tendency to those disorders, 
whether painful or spasmodic, which are of remitting 
character, and which seem to depend exclusively on 
disordered action of the nervous matter ; — and it seems 
highly probable, that many of the medicines, or other 
expedients, which are generally called Stomachics, i, e. 



OF THE ACTION OF DISEASES IN GENERAL, 91 

tliought to improve the appetite and digestion, affect 
especially those actions in the Nervous System, which 
form an essential part of the process by which the gas- 
tric juice is evolved. 

It is obvious that our judgment of the probable course 
and termination of any disease, i. e. our Prognosis in 
any case, necessarily requires a knowledge, both of the 
nature, and usual progress, and consequences, of the mor- 
bid action going on, and likewise of the efficacy, and the 
applicability to that case, of the resources of the Art of 
Medicine now enumerated. 



END OF PART I. 



OUTLINES OF PATHOLOGY 

AND 

PRACTICE OF MEDICINE. 



PAET 11. 

OF FEBRILE DISEASES. 

Arranging the whole subject as far as possible, syn- 
thetically, or systematically, i. e, beginning by an expo- 
sition of those principles which appear to be the most 
general results of the observation of facts in this depart- 
ment of Nature, we here treat of all those Diseases, 
which, when occurring in their most perfect or best 
marked form, are attended with the symptoms of Fever, 
as characterized by the comprehensive definition of Gul- 
len, — " Post horrorem, pulsus frequens, calor major, plu- 
resfunctioneslsessB, viribus prsesertim artuum imminutis." 
These we believe to be essentially distinct from a num- 
ber of other diseased states of the body, which, even in 
their most exquisite form, do not present that peculiar 
combination and succession of symptoms ; and this dis- 
tinction, notwithstanding the obscurity that still exists 

8 



OF FEBRILE DISEASES. 



93 



as to the essential nature of Febrile action, we think, 
practically important ; admitting, however, that those 
diseased states of the body, which, in their perfect form, 
are always attended with fever, present themselves like- 
wise under various circumstances, to be afterwards de- 
scribed, without the accompaniment of febrile symptoms, 
or with an imperfect form of them, and so may be said 
to graduate insensibly into non-febrile diseases. 

Of the Febrile Diseases, we make two great divisions; 
the Inflammations, where we believe the febrile symp- 
toms to be dependent on, or essentially connected with, 
certain local changes that are going on in the circulation 
and nutrition of individual parts of the body, — and the 
Fevers properly so called, where we believe both the 
general febrile symptoms, and any local changes which 
occur, to be the effects of a general change, involving the 
whole mass of blood (whether it originates there or not), 
and most generally depending on the introduction into 
the blood of some kind of morbific poison. 

Of these great classes of Febrile disease, we think it 
important to consider the Inflammations first, because 
the inflammatory diseases are the result of causes of 
more uniform operation ; and because much of what is 
to be said, especially of the more complex and dangerous 
forms of the strictly febrile diseases, must necessarily 
bear reference to what has been ascertained of the his- 
tory and progress of inflammations, and of the effects of 
remedies upon them. 



( 94 ) 



DIVISION I. 

OF INFLAMMATORY DISEASES. 

Still proceeding syntlietically, we state first the most 
general principles that have been ascertained as to that 
kind of diseased action which we term Inflammation, in 
whatever part of the body it may occur, and afterwards 
treat of the Inflammations of individual parts. And al- 
though the Pathology of Inflammation is still imperfect, 
it is so far advanced that it will answer better to state 
what is known of the essential nature of the process it- 
self, and of its various consequences, in connexion with 
the account of its symptoms and external efiects, than 
to treat formally of the proximate cause of Inflammation, 
after having traced its whole history as made known by 
symptoms and ultimate results. 



( 95 ) 



CHAPTER I, 

OF INFLAMMATION IN GENERAL. 

Sect. I. — Of the Primary and Characteristic Pheno- 
mena of Inflammation. 

The term Inflammation — derived from inflammo, to 
burn, and suggested probably in the early ages of medi- 
cine by an erroneous idea of the nature of tbe changes 
which it denotes — has yet been employed, in all ages, 
as a short and significant expression for a combination 
and succession of phenomena, regarded as among the 
most frequent and most important of any \vith which the 
physician or surgeon is conversant ; phenomena conse- 
quent on every mechanical injury applied to the living 
body, and frequently excited, in a greater or less degree, 
by many of the noxious agents to which we give the 
name of poison, and by almost every other influence or 
external cause which is capable of injuriously affecting it. 

The effects of the morbid changes thus denoted, vary- 
ing remarkably in different cases and in different parts 
of the body, resemble, and therefore illustrate, and very 
often combine themselves with, all other modes of diseased 
action of which the living body is susceptible ; under fa- 
vourable circumstances, inflammation is more completely 
under the control of remedies than any other diseased 
state ; and yet we know that it is concerned in producing 
a very large part of the mortality in all parts of the 



96 OUTLINES OF PATHOLOGY AND PEACTICE. 



world. It is therefore, on all accounts, the kind of dis- 
eased action which it is the most important for the Pa- 
thologist to study. And it has been generally agreed, 
that the most distinctive marks by which this diseased 
state in any part of the human body, or of the most ana- 
logous animals, can be recognised, are those employed 
• for that purpose at least so long ago as the time of Cel- 
sus, viz. the combination of pain^ swelling^ heat, and 
redness, in any one part of the body. 

It has been objected, however, to the whole doctrine of 
inflammation as usually delivered, and the very use of the 
term, that the phenomena included under this term have 
been inaccurately and imperfectly generalised, and the 
term itself so vaguely applied, as to have injured the pro- 
gress of science.* 

But the proper conclusion to be drawn from the expo- 
sition of these errors is, not that the term inflammation 
should be abandoned, or that the numerous and accurate 
observations, comparisons, and inferences, made and con- 
firmed by so many medical observers on the diseases 

* " Cree dans Tenfance de la science, cette expression toute meta- 
phorique etait destinee a representer un etat morbide dans lequel les 
parties semblent bruler, s'enflammer, &c. Regu dans le langage, 
sans qu'aucune idee precise lui ait jamais ete attachee, sous le triple 
rapport des sjmptomes qui Fannoncent, des lesions qui la caracteri- 
sent, et de sa nature intime, I'expression infiammation est devenue 
une expression tellement vague, son interpretation est tellement arbi- 
traire, qu'elle a reellement perdue toute valeur; elle est comme une 
vieille monnaie sans empreinte, qui doit etre mise hors de cours, car 
elle ne causerait qu'erreur et confusion." (Andral, Precis (TAnat. 
FatJiol. torn. i. p. 9.) Nous sommes loin de nier 1' existence des 
phenomenes dites inflammatoires, mais nous ne pouvons pas accepter 
la denomination consacree." (Magendie, Lepons sur les Phenomenes 
Physiques de la Vie. torn. iii. p. 383.) " On finit un livre entier 
de toutes les idees que represente le mot inflammation, car il est 
synonyme du mot maladie.'' (lb. p. 445.) 



OF INFLAMMATION IN GENERAL. 



97 



which they have termed inflammatory, should be in any 
degree neglected ; but only that the phenomena, whether 
in the living or dead body, to which this name is to be 
given, should be more strictly defined, the varieties of 
which they appear susceptible more carefully described, 
and the connection between these local changes and the 
concomitant constitutional derangements more clearly 
ascertained, than has often been done. 

In order to give the requisite precision to the general 
notion of Inflammation, as a local change of the condi- 
tion of any part of the body, it seems only necessary to 
include in it, besides the pain, swelling, heat, and red- 
ness, the tendency always observed, even when the 
changes in question are of short duration, to Effusion 
from the bloodvessels of some new products ; speedily 
assuming, in most instances, the form either of coagu- 
lable lymph or of pus.* It is true, that there may be 
inflammation either of so slight intensity, or so short 
duration, as never to shew these, its usual consequences ; 
but we may lay it down as a rule, never to apply the 
term except in cases where we are satisfied that the ten* 
dency to these efl*usions exists, and that, if they do not 
appear, it is only because of the minute scale, or the 
rapid abatement, of the diseased action. A peculiar 
perversion of nutrition^ or of secretion^ we may hold to bo 
essential to the very existence of inflammation ; and all 
descriptions, and all attempts at explanation of the 

* The " nisus aut ad suppurationem aut ad gangreenam," is set down 
by Frank as one of the essential characters of inflanaraation. Of 
these it seems unnecessary here to specify the last termination, inas- 
much as it probably never takes place until other characteristic effu- 
sions have already fixed the character of the diseased state. 

G 



98 OUTLINES OF PATHOLOGY AND PRACTICE. 



clianges to which the term is applied, if thej do not in- 
clude this their most essential peculiarity, we must re- 
gard as necessarily and fundamentally defective. It is 
true, that the various effects which we ascribe to inflam- 
mation, adhesion, suppuration, ulceration, gangTene, are 
very different from one another, and that we cannot sa- 
tisfactorily point out the cause, or . even the mode, by 
which each is effected; but we may be fully assured, 
from ample observation, that all these occur as ef- 
fects of an inflammatory action, originally of the same 
kind ; we can go a certain length in pointing -out the 
conditions luider which each of these results takes. place ; 
and we mav refer to these as o'eneral and established 
facts, in many pathological discussions, on more obscure 
phenomena. 

We may therefore begin this subject by briefly enume- 
rating the local changes^ and the principal varieties of 
these, which are observed., in any part of the body during 
the progress of what we call the state of inflammation — 
including, in this enumeration, both those changes which 
are on so small a scale as to be visible only under the 
microscope (which, of course, have only been satisfac- 
torily seen iu the translucent parts of animpJs), and those 
which make themselves obvious to the unassisted senses, 
and are seen in all the textures. 

Immediately after the application of a stimulus which 
is capable of exciting inflammation — especially if it be 
one which acts on a large surface, as alkohol applied to 
a membrane — a constricted state of the small vessels of 
the part, a.nd an accelerated flow of blood through them, 
have been distinctly seen by various observers ; but this 
state is of short duration, and during it the characteristic 



OF INFLAMMATION IN GENERAL. 



99 



marks of inflammation are not perceived. After a time, 
varying from a few minutes to some hours from the first 
application of the exciting cause, the opposite change in 
the condition of the small bloodvessels is observed ; they 
become enlarged and distended ; the movement in those 
most affected is slower than before ; there is often abso- 
lute stagnation for a time, and often oscillation^ in diffe- 
rent portions of them, and the globules of the blood 
which they contain are found to coalesce into irregular 
masses, in which their individual forms are no longer 
recognised. This is the condition of those parts in which 
the redness and swelling are the most intense. In the 
neighbourhood the vessels are likewise enlarged, while 
the flow through them is more rapid than natural. Over 
the whole surface, and especially where the movement 
of the blood is retarded, many small vessels become ob- 
vious, which were not previously seen. This is no doubt 
chiefly owing to the reception of the globules of the 
blood into vessels previously admitting only its colour- 
less liquid ; but several observers think they have dis- 
tinctly observed the formation of new vessels, by globules 
escaping from the vessels and making tracks for them- 
selves in the surrounding textures. It does not appear 
that either acceleration or retardation of the flow of blood 
is essential to the state of inflammation ; and although 
the latter state is always predominant in the parts most 
severely affected, yet, partly in consequence of the ac- 
celerated flow in the neighbouring vessels, and partly of 
the increased quantity of blood received, more than com- 
pensating for its slower progress through the most dis- 
eased part, the whole quantity of blood returned by the 
veins, from an inflamed part (as in the case of the hand) 



100 OUTLINES or PATHOLOGY AND PRACTICE. 



is found to be greater, and, when the inflammation is 
severe, to be three or four times greater than that re- 
turned, within the same time, by the veins of the oppo- 
site sound organ. 

Within a time, which is likewise various, but often 
very short, from the beginning of these changes, the 
characteristic Effusions of inflammation begin to shew 
themselves, chiefly, perhaps solely, in those parts where 
the flow of blood is retarded ; first, the surrounding 
textures are loaded with a serous fluid ; but gradually 
changes take place in this fluid, which indicate that 
other constituents of the blood have exuded from the 
vessels ; part of the fluid efl^used assumes a gelatinous 
consistence, and forms flakes or layers, which gradually 
become solid. In the semifluid matter first eff*used, 
according to G endrin and others, small globules, thought 
to be decolorised globules of the blood, may often be per- 
ceived ; the matter eff'used certainly, in part, aggregates 
together into somewhat irregular, but nearly spherical 
masses, larger than the globules of the blood, to which 
the names " Globules of Inflammation," and " Exuda- 
tion Globules," have been applied ; and in many cases 
globules of pus, known by their larger size and freer 
motion on one another, and, when observed in mass, by 
their yellow colour, soon appear in this effused matter ; 
and it assumes, more or less rapidly, and more or less ge- 
nerally, the form of purulent matter. 

When the inflammation occurs in serous or mucous 
membranes, the first eff'usions from the bloodvessels go 
only to increase, and probably attenuate, the natural 
exudations from these surfaces ; but as the inflammation 
advances, the fluid thrown out becomes always, as in 



OF INFLAMMATION IN GENERAL. 



101 



other parts, of thicker consistence, as well as more co- 
pious than natural, and often more or less distinctly puru- 
lent. 

Along with the semifluid lymph effused in the earlier 
stage of inflammation, there is often extravasation of 
the colouring matter of the blood, and sometimes of en- 
tire blood ; but most of the inflammatory exudation, in 
the cases to which we give the name of simple or healthy 
inflammation, soon acquires, in most textures, the ap- 
pearance of the coagulable lymph or fibrin, such as con- 
stitutes the bufFy coat of inflamed blood. In this efl'used 
coagulable lymph it is very generally observed that 
canals are gradually formed, into which some of the ca-- 
pillaries of the inflamed texture soon efltise blood ; these 
canals are, in the first instance, of larger calibre than 
the vessels which supply them, but soon contract and 
assume the appearance of vessels (chiefly of veins, when 
the inflammation is of healthy character), in which the 
motion of the blood goes on as in the vessels of other 
parts of the body, and by means of which this new tex- 
ture of the body becomes liable to nutrition and absorp- 
tion, like any of the pre-existing textures. It is thus 
that the permanent Adhesion of inflamed surfaces, and 
the closing of wounds, whether by the first intention (as 
it is called), or by granulation, is efl*ected ; and that in- 
flammation, within due limits, becomes the grand agent 
in repairing injuries attended with loss of substance. 

On the other hand, the inflammatory efi*usions are 
always liable, in a greater or less degree, to the vital 
action of Absorption ; which, although very beneficial 
in the first instance, and indeed essential to the final 
disappearance of the disease, very often, in the more ad- 
vanced stages, extends irregularly to the surrounding 



102 OUTLINES OF PATHOLOGY AND PRACTICE. 



textures, and goes on to an extent which is not required 
for any useful purpose ; and it is in this way, chiefly, 
that inflammation becomes a cause of that irregular 
breach of substance in the solids of the body to which 
we give the name of Ulceration. 

Lastly, when the inflammation, and more or less of 
consequent eff'usion, have lasted some time in any texture, 
it often happens that the parts chiefly afl*ected gradually 
lose their sensibility, change their colour to grey, purple, 
or black, become soft and flaccid, and ultimately putrid, 
their circulation gradually ceasing, and all their vital 
properties being extinguished. This is the termination 
in Gangrene or mortification, often attended by suppura- 
tion and ulceration along the edge of the mortified part, 
which eff'ects its separation from the living by the pro- 
cess called sloughing j while in other cases (as in what 
has been called traumatic gangrene) no such process is 
established to limit the extension of the gangrene, and 
it is arrested only by the death of the patient. 

These obvious changes are attended with less striking, 
but equally characteristic, alterations in the blood which 
passes through the inflamed parts. As the globules 
coalesce into irregwlar masses, much of their colouring 
matter has seemed to some to separate from them(6^m- 
drin) ; as the liquor sanguinis, or clear fluid of the blood, 
exudes from the vessels, it comes forth more loaded with 
fibrin than natural, so as to deposit much of it in the 
solid form, when at rest ; and this efliised fibrin has cer- 
tainly a peculiar firmness of aggregation, for when it 
exudes on the inner surface of bloodvessels where a cur- 
rent is going on, although fluid in the first instance, it 
is not carried^ off by the stream, but " concretes upon, 
and furs over, the inside of the vessel." (Hunter.) 



ii 



OF INFLAMMATION IN GENERAL. 



103 



And again, when a portion of lung is hepatized, or ren- 
dered impervious to air by this effused lymph, its specific 
gravity is rendered distinctly greater than when it is 
condensed by effusion of blood only, as in the case of 
apoplexy of the lung, or in that of the " peripneumonie 
des agonisaus," — resulting only from the subsidence 
of the blood to the lowest portions of the lungs, when 
the heart's action has been much enfeebled, and the 
arterialization of the blood somewhat obstructed. And 
as much of the effused fluid often gradually takes the 
form of purulent matter, the same change has been dis- 
tinctly observed to take place on portions of the blood 
contained in the inflamed vessels themselves. {Gendriw 
— Gulliver,) 

These local changes are always observed to extend 
more or less from the point where they commence, be- 
fore subsiding there. This extension takes place in a 
much greater degree in some varieties of inflammation 
(to be afterwards mentioned) than in others ; but in all 
cases two important observations may be made on the 
extension of inflammation : 1. That it is more apt to 
take place along the texture where it originates, than to 
cross from one texture to another ; and, 2. That it usually 
takes place from the original point, as from a centre, in 
all directions, not following the course either of vessels 
or nerves, and often passing from one portion of a mem- 
brane (as the pleura or peritoneum) to another portion 
lying contiguous to it, although the vessels and nerves 
of this portion arise from a distinct source. 

The symptoms usually and justly regarded as the 
most characteristic of the early stage of inflammation, 
the pain, swelling,' heat, and redness, are by no means 
concomitants of the whole progress which we have now 



104 OUTLINES OF PATHOLOGY AND PRACTICE. 



sketclied. The two latter often disappear long before 
the diseased actions are over ; and the pain is not only 
usually absent in the inflammation of certain textures, 
such as the mucous membranes and the parenchymatous 
viscera, but is necessarily and entirely absent in certain 
cases of inflammation, which nevertheless run through 
the whole course which we have described ; viz. in those 
inflammations which succeed the division of the sensi- 
tive nerves of the eye, or of the lungs, or which affect 
the mucous membrane of the urinary passages in com- 
plete anaesthesia of the lower parts of the body. Never- 
theless, in the natural state, pain readily increased by 
pressure on any part within reach of the finger, is very 
generally a most important diagnostic mark of inflam- 
mation. 

While these local changes are going on to any con- 
siderable extent in any part of the body, the functions 
of that part, and often of neighbouring parts, or of parts 
connected in function with it, are very generally and 
considerably altered, although with varieties which will 
require more special consideration afterwards. Farther, 
a general or constitutional derangement, in a healthy 
constitution, almost uniformly attends them ; and this is 
indicated in two ways. 

First, the blood over the whole system gradually as- 
sumes that change which is expressed by the term 
sizy, or shews the bufFy coat when coagulating ; by 
which we mean that its fibrin and its colourino; matter 
have a tendency to separate from one another when 
the former becomes concrete ; the cause of which ten- 
dency we leave doubtful for the present, only observing, 
that it does not depend on any alteration of the time 



OF INFLAMMATION IN GENERAL. 



105 



requisite for coagulation, being observed under great 
varieties of the time during which the progress of co- 
gulation goes on. In cases of intense or violent inflam- 
mation, two other changes are distinctly observed on the 
fibrin of the blood, besides its increased tendency to se- 
paration from the colouring matter : jirs% that its pro- 
portion to the other constituents of the blood is gradually 
and often greatly increased ; and, secondly^ that the ag- 
gregation of its own particles during the coagulation is 
increased, so that the coagulum formed becomes preter- 
naturally firm or contracted. According to the recent 
observations of Andral, the proportion of the Fibrin to 
the other constituents of the blood is always increased 
when the buffy coat shews itself ; but this is certainly not 
the whole change, on this portion of the blood, which 
then takes place. The increased aggregation of the 
fibrin which separates from the colouring matter (varying 
remarkably even when the quantity of the separating 
fibrin is nearly alike) and the tendency to lateral sepa- 
ration of the colouring and colourless parts of the blood, 
seen even in very thin films of sizy blood (as noticed 
particularly by Schrseder), are characteristic changes 
which cannot be explained by the increased proportion 
of the fibrin. 

According to Gulliver and others, globules of pus, 
or nearly resembling and easily transformed into them, 
are found in the blood in inflammatory diseases long 
prior to the deposition of pus from the vessels, or even 
in cases where no such effusion ever takes place ; and it 
seems certain that there is a tendency to aggregation of 
globules (whether coloured or colourless) in the blood, 
not confined to the vessels where the inflammation re- 
sides. These changes on the blood out of the body are 



106 OUTLINES OF PATHOLOGY AND PRACTICE. 



not yet fully elucidated ; they seem to be liable to some 
variety, and are always gradual, so tbat they are in ^ 
general hardly perceptible in blood drawn very early in 
inflammatoi'y diseases. It is probable, from the micros- 
copical observations already stated, but not fully ascer- 
tained, that these changes are wrought on the blood only 
in the course of its progress through the vessels which 
are the seat of the inflammation. 

Secondly^ In consequence of the existence of local in- 
flammation in any part of the body for a certain length 
of time, that affection of the whole system to which we 
give the name of Constitutional Fever is very generally 
excited, liable to great variations, which will be after- 
wards considered, — commencing by sense of coldness, | 
rigors, and lassitude, which are followed by increased 
frequency and generally increased strength of pulse, in- 
creased heat of skin, and the other symptoms of febrile 
excitement or Reaction, — particularly headache, restless- 
ness, hurried breathing, and general soreness or uneasi- 
ness, denoting a disordered state of the Nervous Sys- 
tem, — attended with thirst and anorexia, and usually 
with a white but moist tongue, costiveness and scanty 
high-coloured urine, and dryness of the skin, denoting 
deficiency of various secretions. This inflammatory 
form of Fever or Synocha is farther marked by the ab- 
sence of certain symptoms which distinguish the dif- | 
ferent forms of what we call Idiopathic fever, — parti- 
cularly by the absence of any specific eruption on the 
skin, or of any of the indications of the dissolved or 
putrescent state of the blood (petechise, &c.) ; and 
again by the absence, during the greatest violence of 
the disease, of those peculiar signs of derangement of 
the nervous system, to which we give the name of ty- 



OF INFLAMMATION IN GENEEAL, 



107 



phoid (the peculiarly overpowering " depressio febrilis" 
and muscular debility, muttering delirium, subsultus 
tendinum and other spasms, stupor, &c.) j which form 
a prominent part of the character of the strictly febrile 
diseases, but not of the simply inflammatory, excepting 
in cases where the nervous systemx itself has been in- 
flamed or injured. 

Of the local changes which constitute inflammation, 
there are, strictly speaking, only two terminations, — the 
one by resolution, or gradual abatement of the disorder- 
ed state of the circulation, and return to its previous 
condition ; and the other by death of the part : the for- 
mer of which appears, on microscopical examination, to 
consist essentially in the gradual renewal of movement 
in the stagnating blood, the separation of its globules, 
which had previously seemed to coalesce, and the return 
of the distended vessels to their former caliber ; the lat- 
ter, to consist in absolute cessation of movement in the 
blood, and then rapid putrefaction, both of the blood 
stagnating in the vessels, and the recent effusions. But 
from what has been said, it will be at once understood 
that, before inflammation can be resolved, there may in 
many instances be such an amount and continuance of 
fluid effusions, or such alteration of the structure, or de- 
rangement of the functions of the solids, or such affec- 
tion of the system at large, as may be either perma- 
nently injurious, or immediately fatal ; and that the 
study of the difl'erent modes of fatal termination of in- 
flammatory diseases, of which we shall presently speak, 
may be prosecuted successfully, and with great practical 
advantage, even while the intimate nature of inflamma- 
tion itself is still imperfectly understood. 



108 OUTLINES OF PxVTHOLOGY AND PRACTICE. 



Sect. II.^ — Of the pvemit state of our hnowledge of the 
essential nature of Inflammation. 

HaAang olfered tbis general sketch of tlie various phe- 
nomena to which the name of Inflammation, or inflam- 
matory action, is given, we may next, before going far- 
ther into details, proceed to inquire, how far the present 
state of our knowledge enables us to form an oj^inion of 
the intimate nature, or proximate cause, as it has been 
termed, of this deviation from the natural condition of 
living parts. That any explanation of these phenomena 
should be very general, and leave much unexplained, 
is no more than we must expect when we remember, 
that all explanation is founded on comparison, and that 
the phenomena in nature which can be brought into 
comparison with the changes in inflamed parts are neither 
numerous nor well understood. Certain principles, how- 
ever, of essential importance in this inquiry may be laid 
down with confidence. 

I. It has been generally thought in this country, at 
least since the time of Hunter and Cullen, that any 
such fundamental morbid changes as have now been 
enumerated, must depend on alteration of the vital 
powers or endov/ments of the body, and that no satis- 
factory explanation of them, on simply mechanical or 
chemical principles, or by any combination of the two, 
is to be expected. It has indeed been attempted, of late 
years, in France to resolve all the phenomena of inflam- 
mation into the mechanical and chemical eff*ects of ob- 



OF INFLAMMATION IN GENERAL. 



109 



struction of the capillaries;* but this will be generally 
regarded in this country as a step backwards, not for- 
wards, in pathology. Considering inflammation as a 
condition of the living body, in which an alteration of 
secretion and nutrition, as well as of the capillary circu- 
lation, is essentially concerned, we may apply to it the 
language of Magendie himself on the physiology of 
these functions : — Sans doute il se passe au sein des 
vaisseaux capillaires des phenomenes que la physique iie 
saurait expliquer : sans cesse de nouveaux materiaux 
sont deposes et reposes dans la profondeur de nos tissus ; 
c'est cet echange mutuel de molecules vivantes qui con- 
stitue Facte important de nutrition. Qui pourrait se 
flatter de soulever le voile dont la nature se plait a en- 
velopper ces mysterieuses fonctions?" {Op. cit. torn. ii. 
p. 134.) And it is important to state briefly the con- 
siderations which seem clearly to indicate, that mere 
mechanical obstruction in the capillaries, and mere 
chemical changes on the blood, whether preceding or 
following that obstruction, cannot suffice for the ex- 
planation of the phenomena of inflammation, as under- 
stood in our time, any more than when the theory of 
obstructed vessels, as laid down by Boeehaave, was 
opposed and refuted by Cullen. 

1. If the mere circumstance of obstruction of the 

* " L'irritation et rinflammation artificiales sont tout simple- 
ment des resultats mecaiiiques." (Magendie, Lecons sur les Phe- 
nomenes Physiques de la Vie, torn. iii. p. 433.) " Inflammation 
differe de ia congestion en ce, que, dans celie ci, il n'y a que dilatation 
des capillaires sans obstruction ni rupture de leurs parois." (lb. 
p. 426.). And again, — " L'elevation de temperature de la partie 
inflamme rend tres bien compte de ces transformations chimiques 
qu' eprouve le sang dont la marche a ete accidentalement suspendue," 
(lb. p. 433.) 



110 OUTLINES OF PATHOLOGY AND PEACTICE. 



capillaries, and arrest of the circulation at a small spot, 
were an adequate cause of inflammation, extending, as 
we so often see it do, to a distance in all directions from 
tlie part injured, we ought to have inflammation in 
every case of such obstruction, e. where a vessel is 
tied or otherwise obstructed, so as to lead to very un- 
usual distension, first of the larger vessels communi- 
cating with it, and then of the small capillaries into 
which they ultimately divide ; which we know not to be 
the case. It may be said, that it is only obstruction of 
acpillaries themselves that can thus derange the capil- 
lary circulation ; but it is easy to produce examples to 
shew, that there may be much obstruction of capillaries 
without inflammation, and that when inflammation is 
excited by any cause which obstructs the capillaries, its 
extent and intensity bear no fixed proportion to the degree 
of obstruction in vrhich it originates. Thus, it is stated 
by Maoendie (tom. iii. p. 431), that the prick of a pin 
excites inflammation on a membrane, only when it 
causes effusion of blood, and so deranges the circulation 
in the capillaries. But we often see considerable effu- 
sions of blood on the tunica conjunctiva of the eye, 
which must obstruct many capillaries, but are neverthe- 
less gTadually absorbed, without exciting any inflamma- 
tory appearance or effusion around them; while, on the 
other hand, a prick of a needle causing little haemor- 
rhage, or a grain of sand producing none, may excite 
violent inflammation, the extent and intensity of which 
will depend on various conditions, quite unconnected 
with the original derangement of the capillary circula- 
tion. In every case of apoplexy of the lung, there 
must be absolute obstruction of very numerous capil- 
laries ; but in many such cases there is no inflammation 



OF INFLAMMATION IN GENERAL. 



Ill 



excited around tlie blood effused ; and in equally nume- 
rous cases there is extensive inflammation of the lungs, 
when the existence of any cause capable, on merely me- 
chanical principles, of obstructing the capillaries, is, to 
say the least, quite hypothetical. Nay, it appears from 
many experiments of Magendie himself, as well as 
others, that the circulation may be obstructed in the 
capillaries to such a degree as to cause death of the 
part, without iuflammation necessarily preceding it ; 
for by injecting animal charcoal into the crural artery 
of a dog, so as to choke up the capillaries, he found 
that he could produce complete death and putrefaction 
of the limb within forty-eight hours, and he sets aside, 
with good reason, the idea of this gangrene being the 
result of inflammation running into that termination 
within that time. (Tom. iii. p. 395.) 

Again, while in these cases there is obstruction with- 
out inflammation, we can give instances, on the other 
hand, of bloodvessels in a state of inflammation where 
there can be no obstruction. Indeed two facts of this 
kind, already stated as to inflammation, seem to be 
quite beyond the reach of the mechanical explanation, 
viz. the doubled or tripled quantity of blood transmitted 
through an inflamed limb in a given time, and the ex- 
tension of inflammation from one fold of the membrane 
to another lying contiguous to it, but fed hi/ other vessels, 
— from the pleura pulmonalis to the pleura costalis, 
from the mucous membrane of the gums to that of the 
cheek, &c. 

2. Even if it were proved that the chief symptoms 
of inflammation are merely the mechanical results of 
obstruction of the circulation in the capillaries, we 



112 OUTLINES OF PATHOLOGY AND PEACTICE. 



should not be entitled to deny the intervention of the 
vital properties of the part in producing the phenomena, 
unless we could explain, on mechanical principles, how 
that obstruction of the capillaries is brought about. 
Now, how can we conceive that the merely mechanical 
action of a grain of sand, or of a still more minute par- 
ticle of the matter of gonorrhoea, on the conjunctiva of 
the eye, should so obstruct the capillary circulation 
there, as to cause all the congestion and effusion which 
are seen in acute ophthalmia, while it produces no such 
eflPect on the living membrane of the mouth, or of any 
part of the alimentary canal ? Still more, how can we 
conceive that cold applied to the surface of the body 
should, on merely mechanical principles, determine an 
extensive, permanent, and fatal obstruction of the ca- 
pillaries, in one distant internal organ only ? 

3. If these difficulties were got over, it still remains 
to be shewn, on mechanical principles, how the obstruc- 
tion of the capillaries can produce the most characteris- 
tic of the phenomena of inflammation, i. e. the effusion 
from the vessels, not merely of serum as in dropsy, or 
of blood as in haemorrhage, but of the liquor sanguinis^ 
holding in solution a much larger proportion of fibrin 
than in other parts of the body : — how this effused 
fibrin can first shew an unnatural degree of aggrega- 
tion and density, and afterwards become vascular and 
organized ; and how the properties of the whole blood, 
the relation of its colouring matter to its fibrin, and 
even the relative proportion of its constituent parts, 
can become altered, apparently by passing through the 
vessels of the inflamed part. Any account of the phe- 
nomena in question, which does not touch these charac- 



OF INFLAMMATION IN GENEHAL. 



113 



teristic changes, may be air explanation of swelling and 
redness, but is no explanation of inflammation.* 

4. If we suppose the mechanical explanation of the 
origin and progTess of inflammation to be satisfactory, 
no explanation is attempted^ nor is it easy to perceive 
how any can be given, of the gradual decline, which is 
equally a part of the history of the disease, as it is of 
all excitement or increase of action that is strictly vital. 
Why should the globules of the blood, when they have 
coalesced and staoiiated, and filled and distended the 
capillaries, gradually separate, and get into motion 
again ; and why should the capillaries shrink to their 
former dimensions? If it be said, that the increased 
impulse a tergo forces forwards the stagnating blood, the 
obvious answer is, that the resolution of the inflamma- 
tion is greatly promoted by the loss of blood, and by 
weakening the heart's action, i, e. by lessening the im- 
pulse d tergo. 

If, again, it be said that the capillary vessels, after a 
time, regain their power of contracting on and propel- 
ling the blood, the answer is, that the vessels in ques- 
tion possess so little contractile power, that even in their 
undisturbed state they are dependent, as Magendie 

* Magendie himself observes, quite correctly, as to the coagula- 
tion of the blood, " La veritable cause de ce phenomene doit etre 
cherchee dans 1' absence du contact entre le li(][uide et les parois de 
ses tuyaux. Qu'elle est done cette harmonie si parfaite dont le de- 
rangement enti'aine de si graves consequences ? Je I'ignore. Elle 
dure avec la vie et s' eteint avec elle.'' (Tom. iii. p. 257-) This is 
asserting that the coagulation of the blood is a vital phenomenon. 
And if so, is it not ahnost self-evident, that when we find the coa- 
gulating part of the blood so much altered, in its proportion to the 
other parts of the blood, and in properties, as it is in inflammation, 
the process by which that alteration is effected must be likewise a 
Tital one ? 

H 



114 OUTLINES OF PATHOLOGY AND PRACTICE. 



has shewn, on the coagulatmg property of the blood it- 
self for any power which they possess of retaining it 
within their own area. 

5. Even if we suppose, that all the phenomena of 
one form of inflammation can be explained on the simply 
mechanical principle of obstruction of the capillaries, 
the theory will still be quite insufficient if it does not ex- 
tend to the varied forms of which the same general series 
of phenomena is susceptible, e. g, on the skin ; the rapid 
extension of the disease in one case, and its limitation 
in another ; its early maturity and decline in one case, 
and its obstinate persistence in another ; its resulting in 
the effusion of serum almost without fibrin in one case, 
of plastic lymph, which quickly becomes vascular, in ano- 
ther, and of purulent matter only, incapable of organi- 
zation, in another, — all being products foreign to the 
usual condition of the part inflamed, and incapable of 
being formed otherwise than by a mysterious agency of 
living textures. 

It will be observed, that these considerations are all 
founded, not on speculation, but on observed facts, at 
least equally well ascertained, and equally guarded from 
fallacies, as any that can be observed in experiments on 
animals. To leave them out of view, in forming an 
opinion of the nature of inflammation, is to reject, not 
the aid of hypothesis, but the evidence of facts. We do 
not say that we explain these facts by saying that in- 
flammation is a vital phenomenon, of which the expla- 
nation must be sought only in the laws of life ; but we 
make the first step to the proper explanation, when we 
place the phenomenon in its proper class among the sub- 
jects of human knowledge ; and from the facts now stat- 
ed we infer, with perfect confidence, that any mechani- 



OF INFLAMMATION IN GENEBAL. 



115 



cal explanation of the kind in question can only reach a 
part, and not the most characteristic part, of the pheno- 
mena of inflammation ; and that, in this as in other in- 
stances, all attempts to resolve the most essential changes 
which go on in the living body, into the laws of dead 
matter, " can only tend to perpetuate false views in 
physiology, and to draw us off from the proper point of 
view, in which the actions of living bodies should be re- 
garded." 

II. The next question is one on which there is more 
difference of opinion among British pathologists. It is, 
whether the phenomena of inflammation can be explained 
by alteration of the vital poiuers of the vessels in which 
the blood moves, or whether they must be chiefly refer- 
red to alteration of other powers^ influencing the condition 
and the motion of the blood in the living body, but inde- 
pendent of any contractions of living solids ? 

In considering this question, we may first state, that 
if inflammation depend only on alteration of the vital 
power of contracting solids, these solids must be the 
vessels, to the exclusion of the heart, all the character- 
istic phenomena being often observed when the heart's 
action is unchanged ; and we may next afBrm, that the 
only vital properties which experiments authorize us to 
ascribe to any vessels is the power of Tonicity, as defined 
and illustrated by Parry, which mainly co-operates with 
and augments the effect of their elasticity, causing them 
to contract when emptied of blood, and to remain con- 
tracted for life ; and which seems to be itself augmented 
on certain occasions, as is shewn by their contracting on 
a stimulus, and remaining contracted until the effect of 



116 OUTLINES OF PATHOLOGY AND PRACTICE. 



tlie stimulus is over, or is counteracted by some otber 
cause. 

It is quite obvious, tbat any increased exertion of this 
power in tbe arteries, particularly if commencing in the 
capillaries and extending backwards, must impede and 
obstruct tbe passage of tbe blood : simple and decisive 
experiments were performed by Hales and by Wede- 
meyer, in wbicb stimulating liquids were injected into 
arteries, and, following tbe course of tbe circulation, 
must bave exerted tbeir cbief effect on tbe smaller 
branches of tbese vessels, and were found to be transmit- 
ted into tbe veins mucb more slowly tban tbe blood it- 
self, or mild liquids injected into tbe arteries. 

As we bave stated tbat one of tbe leading phenomena 
of inflammation is an increase, not only of the quantity 
of blood in the small vessels of the whole part affected, 
but of the quantity transmitted through them in a given 
time into the veins, there is a manifest presumption, that 
the general condition of the vessels concerned in inflam- 
mation must be the reverse of that state of permanent 
tension, which a stimulus acting on living arteries is 
found to produce. Accordingly it has been long known, 
that the capillary vessels, and small arteries of an in- 
flamed part, appear under the microscope distended and 
motionless. 

We need not enter on the question, whether the small- 
est capillaries of most textures of the body bave any con- 
tractile coats at all ; but it is quite certain, that when 
they are in this distended state, there can be no spasm 
or contraction exerted by such coats as they possess, 
capable of maintaining the distended state of the vessels 
behind them. And in a series of observations made in 



OF INFLAMMATION IN GENERAL. 



117 



Edinburgli on tlie arteries leading to inflamed limbs in 
horses, at different parts of tlieir course, and at different 
periods of tlie inflammation, it always appeared that 
these vessels possessed less of the only vital power which 
experiments authorize us to ascribe to them, — that they 
had less power to propel their contents, and contracted 
less, at the moment of death, — than those of the oppo- 
site sound limbs. [Transactions of British Association^ 
1834-5.) 

It may be a question, whether this general state of 
relaxation and distension, which appears clearly to be 
the condition of all the vessels connected with an in- 
flamed part, is or is not the effect of an increased exer- 
cise of their tonic power of contraction in the very com- 
mencement of the diseased state. Into this we need not 
enter. We consider it as certain, that during the whole 
time when inflammation, and efl'usion consequent on it, 
are most distinctly going on, the condition of all the 
vessels leading to and passing through the inflamed part, 
is one not of constriction but of relaxation ; and the 
question before us is narrowed to this, — Does that state 
of relaxation afford a sufficient explanation of the changes 
which take place in inflamed parts ? 

Now, it may be admitted that a general relaxation of 
the arteries and capillaries of any part of the body, giv- 
ing increased eff'ect to the impulse from the heart, is an 
adequate cause for the increased transmission through 
the vessels of that part, for the apparently increased ac- 
tion of the arteries leading to it, and the increased pro- 
pulsion of blood from them when they are punctured. 
But it seems absolutely impossible, that the single cause 
thus assigned should embrace the two opposite pheno- 
mena which are presented by the blood in the vessels of 



118 OUTLINES OF PATHOLOGY AND PRACTICE. 

an inflamed part, — viz. the increased velocity and in- 
creased transmission of blood in these vessels on the 
whole, and the retarded motion or absolute stagnation 
in those points where the inflammation is at its height. 
On the supposition, that the only truly propelling power 
acting on the blood is the heart, and that increased local 
determinations of blood depend only on local diminution 
of the resistance offered by the bloodvessels, we can un- 
derstand that where this resistance is much diminished, 
the blood should pass through in increased quantity ; but 
we cannot understand that where this resistance is least 
of all — where the vessels are absolutely passive, — there 
the opposite change should take place, and the blood 
cease to pass through at all. If the heart's action is 
rendered more eilicient in one set of vessels by a dimi- 
nution of their own tonic power of contraction, we can- 
not possibly admit that it can be rendered altogether in- 
efficient in another set of vessels, merely by a farther 
diminution of that same power ; nor indeed will the 
total loss of that tonic power enable us in the slightest 
degree to comprehend this total loss of efficiency of 
the heart's actions, and consequent stagnation of the 
blood.* 

But if we cannot ascribe the changes in the motion 
of the blood in inflammation to alteration of the contrac- 
tile power of the vessels, still less can we ascribe to that 
cause the other changes essential to the state of inflam- 
mation — the effusion from the bloodvessels of the liquor 

* We speak here of inflamRiation occamng, as it so often does, 
without previous obvious mechanical obstruction to the flow of blood 
through the capillaries, or any impediment to that flow, but that 
which results from the existence of the inflammation itself, and forms 
one of its own phenomena. 



OF INFLAMMATION IN GENEEAL. 



119 



gangiiinis with an increased proportion of fibrin, the con- 
solidation and organization of that effusion, — the conver- 
sion of part of the constituents of the blood stagnating 
in the part, both in the vessels and out of them, into the 
new secretion, or rather excretion, which we call puru- 
lent matter, — in short, any of those characteristic phe- 
nomena by which alone we distinguish inflammation 
from local terminations and congestions of blood, con- 
stantly occurring in the system, but consistent with 
health, or even necessary to life. 

We may observe in particular, that two distinct and 
apparently opposite changes are distinctly referable, in 
different cases, to inflammation as their cause — extra- 
vasation of certain matters, and ulcerative absorption of 
others. On the supposition, that the power moving the 
blood through an inflamed part is simply the impulse 
from the heart, more or less altered by passing along the 
arteries, and modified in its effect at the part in question 
only by mechanical causes, especially by some obstruc- 
tion in the capillaries, we can understand that when the 
impulse is greater than natural, extravasation should 
take place, and that when it is less than natural, there 
should be unwonted absorption. But this theory is per- 
fectly inadequate to embrace the opposite phenomena, 
viz. rapid inflammatory extravasation when the impulse 
is feebler than natural, and rapid ulceration when it is 
stronger than natural. Yet experience shews, that both 
these phenomena occur frequently, as effects of inflam- 
mation, — the former ( e. g.) in cases of diffuse inflam- 
mation of the cellular substance or of the peritoneum, in 
the nearly latent pleurisies succeeding fever or small- 
pox, &c. ; the latter in cases of phagedenic ulceration. 
It is quite certain that neither the amount of effusion 
nor the amount of absorption, consequent on inflamma- 



120 OUTLINES or rATIIOLOGY AND PRACTICE. 



tion, bears any fixed relation to the degree of impulse 
with which the blood is sent through the inflamed parts. 

Neither can any conceivable alteration of the vital 
contractile powers of arteries explain the essential dis- 
tinctions of different cases of inflammation on the skin — 
the erythematic; scaly, vesicular, pustular, &c., varieties, 
very often depending, as we knoAV, on differences, not in 
the constitution of the patients, but in the cause of the 
disease. 

We are thus led, by ascertained facts, and, as we be- 
lieve, irresistible inferences from these, to the conclusion, 
that inflammation and its effects are inexplicable by any 
alteration of the contractile power of the living solids 
concerned in it ; and necessarily imply an alteration of 
vital properties, by which the constitution of the blood, 
its relations to the surrounding textures, and its move- 
ment through them, are determined, but which are quite 
distinct from any contractions of living solids. That 
such living properties exist, that they effect the changes 
taking place at insensible distances among the particles 
of the blood, and that they are altered in inflammation, 
will hardly be denied by any pathologist. That they 
are capable of affecting the visible motion of the blood, 
will appear a rash assertion only to those who have not 
accustomed themselves to consider the evidence by which 
it is supported. 

In fact, inflammation is only one of a number of cases, 
of constant occurrence in the animal economy, where 
some peculiar cause (commonly, but vaguely, called a 
stimulus) is applied to the capillary vessels of one part 
of the body, and determines an increased flov»r of blood 
towards, and increased transmission through that part, 
?. e. the opposite effect to that which experiments on the 
application of stimuli to arteries would lead us to expect. 



OF INFLAMMATION IN GENEEAL. 



121 



Whether we apply to such cases the adage, " Ubi stimu- 
lus ibi fluxus," or use the term " adfluxion," or " move- 
ment of turgescence," or " solicitation of fluids," or 
speak of a vital erection of vessels, they all present a 
phenomenon which must be studied and understood, be- 
fore an accurate notion can be formed of many leading 
facts in the history of the living body, in health and dis- 
ease. When air is admitted into the cells of the lungs, 
when food is received into the stomach, when a strong 
impression is made, or sensation excited in any organ of 
sense, when an embryo begins to grow in the uterus, — 
this increased flow into those capillary vessels where 
these causes act, is immediately perceived, and is es- 
sential to the important changes which follow ; one re- 
sult of which changes, in several of these cases, is 
an alteration of the constitution of the blood itself. 
In all these instances, as well as in that of inflamma- 
tion, it is impossible to ascribe to the stimulus, which 
produces what we call the increased action of the part, 
any power of exciting the only vital power (that of tonic 
contraction) which the bloodvessels of that part pos- 
sess ; on the contrary, we might be disposed to ascribe 
the determination of blood to the impression made at the 
extremities of the vessels, causing relaxation of them, 
and thus giving increased efl'ect to the impulse from the 
heart ; but this theory is at once checked by two simple 
considerations ; firsts that a stimulus, such as air, applied 
to any single vessel or set of vessels, causes constriction, 
and should therefore impede the transmission of these 
fluids, instead of promoting it ; and, secondly^ that in 
extending our views to other living beings, we find pre- 
cisely similar " movements of turgescence" excited by 
similar impressions on capillary vessels, in the lowest 



122 OUTLINES OF PATHOLOGY AND PRACTICE. 



animals, and in tlie whole vegetable kingdom^ where 
there is no heart, and where the existence of any cause 
of motion, acting on the principle of impulse from behind 
on the moving fluids, has never yet been proved. These 
facts afford a strong presumption, that in all these cases 
the impressions made on the capillaries, and on the 
blood contained in them, solicit the flow through them 
on the principle of a vital attraction of the bloody rather 
than of relaxation of the vessels. 

It would be out of place here to go into details on the 
other phenomena of living bodies by which this conclu- 
sion may be supported ; but we may briefly state the 
following grounds for the belief, that the fluids in living 
bodies are subject to a cause of motion, peculiar to the 
living state, but independent of any impulse, or change 
of impulse, from living solids : — 

1. The movements of the sap in vegetables are equally 
essential to their life, and minister to the same functions 
of nutrition and secretion as in animals, yet no contrac- 
tions of solids by T%diich this motion can be explain'ed 
have been detected ; and, in the cases where the cause 
of the motion of the sap has been most carefully inves- 
tigated, it seems well ascertained that no such contrac- 
tion exists. The observations of Du Trochet seem 
clearly to prove, that the power of imbibing fluids resides 
in the spongioles at the ends of the roots of vegetables, 
and that its exercise is unattended with any movement 
of the substance of these spongioles. And in the case 
of the Chara, and other cellular plants, where the mo- 
tion of the globules contained in the sap is so easily per- 
ceived, it seems nearly ascertained, particularly by the 
most recent observations of the same author {Ann. des 
Sciences Wattirelles)^ that the cause of the motion of the 



OF INFLAM>IATION IN GENERAL. 



123 



fluid resides, indeed, in tlie granular matter whicli lines 
certain portions of tlie sides of tlie elongated cells com- 
posing tlie plant, but that the power which this matter 
exerts is of the nature of attraction and repulsion, cer- 
tainly not of contraction and impulse. 

2. The same observation applies, in ail probability, to 
the very similar movements of fluids in various of the 
lowest of the animals — in sponges, in the polypes called 
tubularia and sertularia, and in many animals, consider- 
ably higher in the scale, in which the circulation is 
wholly or partially of the kind called diffused^ i. e. not 
confined to vessels. That the movement in some of 
these cases may be attended by, or even dependent on, 
the impulse of ciliw, is very possible ; but the case of the 
sponge and the chara are sufficient to shew, that certain 
forms of living matter can impress a regular progressive 
motion on fluids independently of such impulse ; and the 
latter case (as lately explained by Du Trochet) may even 
induce us to suppose, that the power of contraction resi- 
dent in living solids is only a particular mode of exertion 
of those vital powers of attraction and repulsion which 
subsist both in certain portions of all living textures, and 
likewise in the " chair coulant" of living fluids. 

3. In the commencement of the existence of all ani- 
mals, as certain definite forms are assumed by the ger- 
minal membrane and the semifluid granular matter in 
contact with it; so certain definite moving powers must 
not only have been exerted before the existence of heart, 
or arteries, or blood, or of any texture capable of con- 
traction, but must have been the essential cause of the 
existence of all these things ; and, at a considerably later 
period of the existence of the embryo of vertebrated ani- 
mals, there is no moving power, acting in the way of 



124: OUTLINES OF PATHOLOGY AND PRACTICE. 

contraction and impulse, to wliicli we can ascribe that 
continued entrance of the fluids contained in the uterus 
into the filaments of the spongy chorion, which is essen- 
tial to the groAvth of the whole ovum. 

4. At all the later periods of the existence of the 
higher animals, there is one set of vessels contained in 
them, into which fluids are introduced, and in which 
fluids are moved, steadily and forcibly, in a manner 
wholly inexplicable by any power of contraction which 
experiments authorize us to ascribe to the vascular coats, 
viz., the absorbent vessels, which are now generally be- 
lieved to have no open mouths, and in which no contrac- 
tile powers have ever been detected, except such as we 
have ascribed to arteries, and any exercise of which, as 
in the case of the arteries, would necessarily retard the 
passage of a fluid. 

5. While it seems perfectly ascertained that the ex- 
ercise of the only vital power of contraction resident in 
arteries must be an additional impediment, instead of 
an auxiliary, to the heart's action in keeping up the 
sirculation, it has long been observed, that the various 
obstacles opposed to the motion of the blood through the 
small arteries, and the very moderate degree of pres- 
sure, by which (as Sir C. Bell justly observed) the im- 
pulse of the blood in the larger arteries may be arrested, 
render it highly probable that some auxiliary power co- 
operates with the vis d tergo to maintain the flow through 
the capillaries. And this probability becomes almost a 
certainty when we advert to the effect of a ligature on 
a large artery, which uniformly leads to distension, not 
of the obstructed artery, but only of the collateral 
branches, and to shrinking and collapse of the portion 
of artery which intervenes between the ligature and the 



OF INFLAMMATION IN GENEKAL. 



125 



last branches above it, — the blood gradually deserthig 
the trunk of the artery, and entering those branches 
only, by which it can be conveyed to capillaries where 
vital actions are in progress. This desertion of the por- 
tion of an artery above an obstruction, and seeming pre- 
ference of anastomosing branches, is not only ascertained 
by subsequent examination of the state of the parts in 
such cases, but has been witnessed on a small scale under 
the microscope by Haller and other observers.^ 

6. A very careful microscopical inspection of the 
phenomena of the capillary circulation led Haller long- 
ago to the conclusion, that it is " de toute necessite" to 
admit the existence of a cause of motion there, to which 
he gave the name of Attraction, independent of the con- 
tractions of the heart or bloodvessels. This conclusion 
has been adopted by most subsequent microscopical ob- 
servers in Germany, and although it has been opposed 
by the authority of Magendie and of Poiseuille in France, 
yet it may be confidently asserted, that no satisfactory 
explanation has been given, on any other principle, of 
some of the facts on which it is rested.f 

* We lay no stress on the instances on record, of the foetus com- 
ing to a considerable size without a heart, because we have no well 
authenticated case, in Avhich such a foetus has existed alone in the 
womb, L e. in circumstances precluding the possibility of the circu- 
lation being maintained by help of the contractions of the heart of a 
true foetus ; but it is right to mention, that cases of the kind have 
occurred, in which competent observers have doubted that any such 
assistance was given to the circulation in a foetus without a heart. 
(See Graves, m Dublin Journal.') 

t We may mention, in particular, the observations of Haller on 
blood escaping from vessels between the layers of a living membrane, 
and nevertheless pursuing its course in a regular stream for a time, 
even against the influence of gravity ; and his observations on the 



126 OUTLINES OF PATHOLOGY AND PKACTICE. 



7. Physiologists are now generally agreed, that the 
phenomena of the coagTilation of the blood, and the 
varieties to which that process is liable, imply the ex- 
istence of certain living properties or powers in the 
fibrin, and particularly of a peculiar attraction or tend- 
ency to aggTegation in the particles of that substance, 
under certain circumstances. And of the importance 
of this living property to the circulation of the blood, 
we are vrell assured by the recent and important expe- 
riments of Magendie, in which it appeared, that when 
the blood is in a great measure deprived of its fibrin, or 
when the coagulating property of that constituent of 
the blood is destroyed by the addition of alkali, the cir- 
culation in the capillaries can no longer be maintained ; 
■ — this preternaturally fluid blood (although hardly, if 
at all, inferior in density to healthy blood) being extra- 
vasated from them in various parts of the body, and 
particularly in the lungs, nearly as it is in many cases 
of malignant fevers. Now, — knowing, as we thus do, 
that the presence and the coagulating property of the 

regular oscillations of globules in limited portions of small vessels. 
On this last phenomenon Poiseuille asserts, and Magendie agrees 
with him, that it is to be ascribed to the impulse of the heart's ac- 
tion, and the resistance of the bloodvessels (even although taking 
place in vessels the coats of which are not seen to contact, and which 
are not seen to communicate with any of the larger vessels) because 
it is found to he si/nchronous with the heart's action. (Magendie, 
Legons, Sfc. torn iii. p. 275.) But this explanation is wholly inap- 
plicable to the case, repeatedly noticed by Haller, by Kaltenbrunner, 
and others, in which these regular oscillations go on, particularly in 
the neighbourhood of inflamed parts, long after the heart is at rest, 
or has been cut out of the body. (See Haller, Mem. siir le Mouve- 
ment du Sang, Exp. 222, et seq. ; Kaltenbrunner, in Journal de 
Physiologie, torn, viii.) 



OF INFLAMMATION IN GENERAL. 



127 



fibrin constitute the power, hj whicli the blood is re- 
tained in the vessels in the natural state of the circula- 
tion, — v/hen we meet with a case where the blood in 
one portion of the body undergoes such a change, that 
the quantity of its animal matter taking the form of 
fibrin, and the tendency to aggregation of this matter 
are increased, should we not expect to find the blood 
accumulate in that part of the body ; — coming under the 
influence of a peculiarly augmented principle of attrac- 
tion there, equally as we know that, when the heart's 
action is very feeble, it will come under the influence 
of the principle of gravitation in any part of the body ? 

From all these facts we think ourselves justified in 
inferring, that inflammation consists essentially in a 
local increase of a vital property of attraction existing 
among the particles of the blood, and between them and 
the surrounding textures, and with which other vital 
properties are connected, and simultaneously excited. 
That the proximate cause of inflammation, although 
affectinof the constitution of the blood, does not reside in 
blood only, but primarily in the agency on the blood of 
the solids through which it passes in the capillary vessels, 
appears clearly from the limitation of the disease, to a 
certain locality in the body, from the fact of its easy 
reproduction, for a long time, or for life, in the vessels 
which have once been the seat of it, — and from other 
facts to be mentioned as to inflammatory efl'usions. In 
the blood itself, the increased attraction seems to take 
place, both among the particles of the fibrin which, in 
union w^ith the serum, constitute the liquor sanguinis in 
the living vessels, and in those particles, of nearly simi- 
lar matter, which constitute the bodies of the globules ; 



128 OUTLINES OF PATHOLOGY AND PRACTICE. 



the increased aggregation of both, and increasing num- 
ber of the former, being characteristic of inflamed 
blood. 

The increased flow to the inflamed part, and probably 
the gradual relaxation of the vessels leading to it, are the 
consequence of these alterations, just as the acceleration 
of the flow of blood through the lungs, on the admission 
of air there, is the consequence of the changes, partly 
chemical but partly vital, thereby brought on the blood ; 
or as the increased flow to the uterus during gestation, 
to the stomach during digestion, or to any secreting 
organ to which a stimulus is applied, is the consequence, 
not the cause, of the vital changes to which the blood in 
these organs is subjected on such occasions. When the 
vital properties of the blood and its relations to the 
living solids shall have been more carefully scrutinized, 
this proposition will acquire more precision ; but even 
at present it is obvious that we assert nothing which is 
not susceptible of demonstration, in asserting, that such 
a vital power of attraction or aggregation among certain 
particles of the blood exists in the natural state ; that it 
is the cause of the coagulation of the blood, i. e. that it 
is the cause of any j)ortion of the constituents of the 
blood taking the form of fibrin ; that it is concerned in 
regulating the circulation in the capillaries ; and that it 
is materially augmented in an inflamed part, — as appears 
both from the larger quantity of the blood which takes 
the form of fibrin, and from the greater aggregation of 
the fibrin itself, both in the blood in the vessels and in 
the matter extravasated there. And thus it appears 
sufficiently ascertained, that the afliux of blood to the 
inflamed part, its stagnation there, and the most import- 
ant of the changes which it undergoes, are included in 

4 



OF INFLAMMATION IN GENERAL. 



129 



this general proposition, that the fibrin contained in the 
blood in that part of the body, is affected, during the 
state of inflammation, with the same change of property 
to which, when we see it in the fibrin that constitutes 
the bulk of muscular fibres, we give the name of rigidity 
or Tonic Spasm. 

Having dwelt so long on the intimate nature of in- 
flammation itself, we may state in a few words all that 
is. known of the nature of the changes already described 
in general terms as its natural effects. These eflects 
must be regarded, indeed, at present, as nearly ultimate 
facts in pathology, and we have already referred to them 
as illustrating the nature of the change from which they 
result. Instead of attempting an explanation of them, 
pathologists are more disposed to refer to them as prin- 
ciples, serving to explain other and less familiar pheno- 
mena ; but much may be done to make our knowledge 
of the real nature of these eff'ects more minute and pre- 
cise. 

When we see the lymph thrown out of vessels in the 
state of inflammation, gradually become concrete, take 
the form of flakes, and then of membrane, and then form 
elongated cells into which the blood of the neighbouring 
textures is received, and in which it continues its motion, 
we can' say in general terms, that this lymph exhibits 
vital properties similar to those by v/hich the original 
organization of the germinal membrane of the egg is 
determined. But it is important to observe two things ; 
first^ that this vital property resides peculiarly, if not 
exclusively, in that efl'usion v/hich takes place from the 
vessels during inflammation, and even during inflamma- 
tion of a particular character and in a particular stage. 

1 



130 OUTLINES OF PATIIOLOOY AND PRACTICE. 



For, iiotAvitlistaiidiiig some doubts which have been ex- 
pressed on the subject, it seems nearly ascertained, that 
neither blood itself, nor any other effusion from unin- 
flamed vessels, nor purulent matter, nor the effusions 
from certain varieties of inflammation [e. g. scrofulous 
or erysipelatous) are capable of thus becoming vascular 
and organized. And the useful purposes which inflam- 
mation serves in the animal economy depend essentially 
on this, that it is the process by which portions of the 
blood are thus prepared for the vital changes by which 
they are to close wounds, and repair breaches of texture. 

Secondly^ It is to be observed, that the property of 
plasticity is communicated to the effused fibrin by the 
agency of the neighbouring living solids. It is obvious 
that the particles of effused fluid which are farthest from 
the solid inflamed textures, are those which shew least 
of this property, and most easily degenerate into pus ; 
and this difference has been distinctly observed under 
the microscope. " The fibrin, as it coagulates on the 
raw surface, forms exudation globules (or ' globules of 
inflammation'), or cytoblasts, many of which cohere in 
layers, and compose the false membrane. The layers 
of globules in immediate contact with the living tissues 
become cells, which then undergo transformation, accord- 
ing to the nature of the texture to be reproduced." 
(Gerber's General Anatomy, p. 9, and fig. 102-3, 205, 
219, 243.) There is some difference among micros- 
copical observers as to the questions, whether any glo- 
bules analogous to these exist in healthy blood ; whether 
they increase in number merely by contact with living f 
solids in the healthy state ; and whether, by means of 
them, adhesion may be effected between cut surfaces in- 
dependently of inflammation ; but there seems to be no | 



OF INFLAMMATION IN GENERAL. 



131 



doubt of the number of these globules or corpuscles being 
first greatly multiplied, and then becoming the scene of 
other vital changes, in the immediate vicinity of inflamed 
surfaces. lb., pp. 29, 30, 34, 35, 83, 84. 

Agahi, when we see the yellow globules of pus gra- 
dually mixing with the other exudations in an inflamed 
part, and often aggregating together towards the centre 
of these efinsions, we see that another vital change, be- 
sides the deposition from the bloodvessels of an unusual 
quantity of one of the natural constituents of the blood, 
— that a new secretion, or rather excretion, because des- 
tined to discharge from the body — is established. The 
observation of Mr Hunter, that in external parts this 
efibct of inflammation is favoured by exposure to air, 
and the effiision of plastic lymph by seclusion from 
air, is one circumstance clearly afi*ecting the formation 
of this product. Another circumstance, which seems 
evidently to favour the formation of purulent rather 
than of plastic matter, out of the deposits from the blood, 
is a certain distance from the inflamed surface, imply- 
ing that the vital influence which passes from the solids 
to the fluids concerned in the process must be weakened 
in intensity. " The exudation globules, which lie be- 
yond the vivifying influence of the surface of the wound, 
and exposed to the action of external agencies, cannot 
long retain their vitality ; forsaken, as it were, by the 
organizing principle, they begin to degenerate in their 
organization, and to suffer changes in their chemical con- 
stitution ; while those that continue in immediate contact 
with the living structures advance in their organization." 
{Gerher, p. 90.) " The enveloping membranes of the 
cytoblasts which are remote from the surface of the 
wound crack, the masses into which they divide become 



132 OUTLINES OF PATHOLOGY AND PRACTICE. 



granules ; the nucleus splits into granules ; aiid tlie cy- 
toblast membrane is transformed into a pus membrane, 
wliicli is now foreign to tlie organism." {Gerher^ p. 113, 
and fig. 96 and 206.) It is farther to be observed, that, 
according to the observations of Gendrin, the formation 
of pus takes place within the vessels of an inflamed part, 
as well as in the matter which escapes from them ; that, 
according to Andral, matter apparently purulent has 
been found within the coagula in the large vessels or 
heart, when there has been no abscess or suppurating 
surface in the body ; that, according to Mr Gulliver, 
when inflammation has lasted some time in any import- 
ant organ, globules of pus, or rather of softened fibrin, 
ready to pass into the condition of pus, may be recognised 
in the blood {Phil. Trans. 1838) ; and again, that a 
small quantity of pus, vvhether in the blood, or in a se- 
rous cavity, acts like a leaven, and speedily leads to the 
production of a great deal more. {Gulliver in Tramla- 
tion of Gerher^ p. 104.) 

Mr Hunter puts the question, " What is the use of 
the secretion of pus ?" and confesses himself unable to 
answer it. We may a^pproxima^te, at least, to an answer 
by observing, that all living action, without exception, 
is probably attended with diminution or loss of vitality in 
the acting particles, and thereby ultimately leads to the 
formation of fluids, which, if retained in the living body, 
act as poisons. The locally increased and altered living 
action of inflammation, when of a certain duration, and 
in a certain lower grade of intensity, or at a certain dis- 
tance from the living influence of the existing solids, is 
subjected to the same law, and can only terminate fa- 
vourably by the expulsion of the excretion which is thus 
formed. We shall afterwards see, that it is at all events 



OF INFLAMMATION IN GENERAL. 133 



a fact, that, whenever purulent matter is directly mixed 
with the blood, it acts on the system as a poison ; and 
that its very rapid formation is characteristic of a spe- 
cific form ,of inflammation, attended Vv^ith depression of 
vital power. 

When we see an ulcerated surface extending itself 
around an inflamed and suppurating j)art, we can only 
say, that, in consequence of the continuance of inflamma- 
tion, in many instances in consequence of pressure or of 
continued external irritation, maintaining and extending 
the local inflammation — the vital process of absorption, 
always usefully active where inflammatory efl'usions are 
of some standing, has extended to a part of the pre- 
viously existing textures. 

Mr Hunter shewed that there may be great effusion 
of pus without any ulceration ; and again, that there 
may be much breach of substance and change of form in 
the solids of the body by absorption, as from pressure, 
without effusion of pus ; and hence he inferred, that the 
loss of substance in ulceration is always to be ascribed 
to absorption only, — never in any degree to solution of 
the solids in the pus or ichor of the sore. But Mr Key 
has made it probable that this inference was too hasty, 
and that a solution, at least partial, of solids in extra- 
vasated fluid, does in general precede their absorption 
{Med. Chir. Trans, vols, xviii. and xix.); and this in- 
deed, according to Dr Prout, would seem to be a preli- 
minary condition to all absorption of portions of the liv- 
ing body itself, whether in the living or dead state. 

The agents employed in this absorption are now gene- 
rally believed to be the veins, at least as much as the 
lymphatic vessels; but according to the most recent 
anatomical researches, both these sets of vessels are filled 



134 OUTLINES OF PATHOLOGY AND PRACTICE. 



in the same way, viz. by lateral transudation. The com- 
mencement of ulceration, as an effect of inflammation, 
implies merely that the attraction by which extravascu- 
lar matters are constantly taken into the small veins 
preponderates over that by which portions of the blood 
pass out of the capillaries. Some observations of Mr 
Key seem to shew distinctly, that, by this attraction, part 
of a living texture may be made to enter the vessels of 
a membrane lying contiguous to that texture, but sup- 
plied with blood from a different source. {Med. Chir. 
Trans, loc. cit.) 

Lastly, When we see mortification and sloughing suc- 
ceed after a time to the previous changes in inflamed 
parts, we can do no more than state the fact, that the 
excitement and change of vital properties in the stagna- 
ting blood, and in the textures in which it stagnates, are 
naturally succeeded, after a certain time, by the loss of 
all vital properties. It has been thought, that this is 
sufficiently explained by the mere circumstance of ab- 
solute stagnation of the blood necessarily arresting all 
the living functions, and thereby allowing of putrefac- 
tion, first in the blood, and afterwards in the surround- 
ing textures ; but it is very doubtful whether this ex- 
planation is sufficient. It is true that, in the experi- 
ments of Cruveilhier and Magendie, the injection into an 
artery of a living animal, of mercury or charcoal, or 
various other substances which, when they arrive in the 
capillaries, choke them up and arrest the circulation, 
was followed by rapid gangrene of the limb, — complete, 
in one of the experiments of Magendie, in forty- eight 
hours after the injection. And it is also true, that gan- 
grene occurs as a consequence of inflammation chiefly in 
those cases in which the general circulation is so en- | 



OF INFLAMMATION IN GENERAL. 



135 



feebled, that absolute stagnation of the blood in the in- 
flamed parts may be supposed to be much more easily 
produced than in the natural state. But we see, every 
day, in cases of ligatures applied to the larger arteries, 
or of obstructions from various causes occurring there, 
just as in the case of aneurisms, — and we know in ex- 
periments, where portions of blood have been inclosed 
between ligatures on the vessels of living animals, — 
that the blood in the larger vessels may stagnate and 
remain perfectly at rest for a long time without putre- 
fying, and therefore we cannot regard its stagnation in 
the small capillaries as a sufficient cause for its putre- 
fying so rapidly as it does in many cases of gangrene. 
And in attending to cases of inflamm.ation running to 
gangTene, we may often see this event take place where 
there is neither such extreme depression of the circula- 
tion, nor such intensity or endurance of the inflamma- 
tion, as to entitle us to suppose that the blood is more 
completely or longer stagnant in the inflamed part than 
in other cases where no such result follows. We may 
conclude, therefore, that the death of the blood, and of 
the textures surrounding the blood, in inflamed parts, is 
an effect, at least in part, of the previous changes of 
them during the state of inflammation, — not merely of 
the cessation of movement; — and that, in the experi- 
ments above noticed, the rapid accession of gangrene 
ought to be ascribed, not merely to the circulation being- 
stopped in the capillaries, but to the minute structure 
of the blood being injured by the mechanical means em- 
ployed, and its vitality therefore quickly destroyed. 

The loss of vitality in an inflamed part has been pro- 
perly compared to the loss of vital power in a muscular 



136 OUTLINES OF PATHOLOGY AND PEACTICE. 



part violently exercised, where, according to the usual 
but metaphorical expression, the irritability has been 
exhausted, and where, we have reason to believe, that a 
certain portion of the muscular substance has been dis- 
organised, and its absorption, with a view to expulsion 
ly the excretions, rendered necessary. The explana- 
tion thus attempted is not sufncient, because we cannot 
assert that the tendencv of inflammation to ofanofi-ene 
bears proportion to any observed increase of vital pro- 
perties of inflamed parts, in the earlier «:tages of the dis- 
ease. But it is to be observed, that, in the greater num- 
ber of cases, where we see gangrene succeed to inflam- 
mation, either the inflammation is of a specific charac- 
ter and attended with typhoid fever, and peculiar de- 
pression of vital powers (as in plague, cynanche ma- 
ligTia, the bad form of measles, or small-pox, or erysi- 
pelas, &c.), or it coexists with another disease, or with 
the influence of some other agent on the body, as when 
it attends continued fever, or succeeds to the effect of 
a violent concussion (constituting the traumatic gan- 
gTene). or occurs as a sequela of some of the contagious 
febrile diseases, or as an accompaniment of some debili- 
tating chronic disease, as palsy, dropsy, or scurvy, or as, 
in part, an eff'ect of inflamed or diseased arteries. In 
all such cases, the concurrence, with the inflammation, 
of a peculiar influence weakening the circulation, mav 
be recognised ; and in several of these it is pretty cer- 
tain that this debilitating influence acts, not merely by 
enfeebling the solids by which the blood is propelled, 
but by modifying the constitution of the blood itself, 
and rendering it more prone to death and to putrefaction, 
than it otherwise would be. 



OF INFLAMMATION IN GENERAL. 



137 



The excitement of general fever by local inflannna- 
tion mnst also be regarded as a general fact in patho- 
logy, more snsceptible of application to the account we 
are to give of other facts, than of explanation in itself. 
Yet there are some principles in this fundamental depart- 
ment of pathology which may be stated with confidence, 
and which it is of importance to keep in mind. 

1. We may set aside entirely the supposed interven- 
tion of a vis naturae medicatrix in this as in all other 
cases where we attempt to give an account of the diseas- 
ed conditions of the body ; — not because there are not 
many of them, in which a wise and benevolent design 
may distinctly be traced, but because the reference to 
this design does not explain Aoic , but only ic/u/, any par- 
ticular changes happen. It is an introduction of final 
causes, into an investigation of which the object is the 
determination of physical causes only ; and the specula- 
tion is rejected, not as false or unphilosophical, but 
simply as misplaced. 

2. We may set aside also the idea of the general fe- 
brile reaction being really effectual in resolving the lo- 
cal inflammation, because we know that the resolution 
of the inflammation often takes place when the violence 
of the fever is over; and is often obviously promoted by 
means which greatly lessen the action of the heart. 

3. We cannot give an opinion with equal confidence 
as to the notion of a spasm of the extreme vessels being 
excited, when fever supervenes on local inflammation : 
we know that, during the greater part of inflammation, 
the condition of all the vessels of the afl'ected part is one 
of relaxation and weakness, not of constriction, and we 
must regard it as doubtful whether the true capil- 



138 



OUTLINES OF PATHOLOGY AND PRACTICE. 



laries, in any texture, are capable of spasm. But many 
observers agree, tliat an unusual constriction of the ves- 
sels of a part becoming inflamed may be perceived wben 
tbe disease is beginning, and the notion of Hoffmann 
and Cullen, as to the extension of this preliminary state 
of the vessels over the system at large, is a plausible 
conjecture. It is at all events certain, that the pheno- 
mena which were considered by them as indicating 
spasm of the extreme vessels, — the cause of coldness in 
the outset, — the diminution of excretions by the skin, 
the bowels, and the kidneys, as well as of the secre- 
tions employed in digestion, and the suspension of the 
function of nutrition, — are real and important : they 
indicate that many of the vital actions going on in the 
capillary vessels are deficient during the febrile state ; 
they justify the inference that the blood in this state 
does not circulate so freely, through many of the small 
capillaries, as in the healthy state, and probably is re- 
turned in larger quantity to the heart by the larger of 
those small arteries which communicate with veins ; 
and this temporarily obstructed state of the capillary 
vessels may certainly be regarded as an adequate cause 
of the temporarily increased action of the heart during 
fever; just as a permanently obstructed condition of the 

* It was ingeniously suggested by the late Dr Fletcher, that if all 
inflammations commence, as microscopical observations seem- to shew 
that some of them do, by constriction of the vessels immediately 
concerned, we have only to suppose this condition extended to the 
small vessels generally to produce that state of the capillaries which 
seems characteristic of fever ; and which, over the system at large, 
may very well be supposed to co -exist with the subsequently relaxed 
and distended condition of the vessels actually inflamed. (See 
Fletchers Pathology. Edin. 1842.) 



OF INFLAMMATION IN GENERAL. 



139 



aorta is universally regarded as an adequate explanation 
of the permanently excited action, and ultimately of the 
hypertrophy of the heart, in chronic disease. 

But two questions, neither of which we have any reason 
to suppose insoluble, remain for solution, before we can 
give a satisfactory account of the febrile state, as excited 
by inflammation : — 1st, Whether the deficient condition 
of the vital actions in the capillaries is owing merely to a 
general constriction of the smaller arteries, or whether the 
auxiliary vital powers, which we believe to influence very 
much the fluids in the capillaries, are here primarily de- 
ranged ; and, 2dly, Whether the general derangement of 
the vital actions in the capillaries over the body is to be 
ascribed to the change on the blood in inflammation, or 
whether an influence of the nervous system is essentially 
concerned in producing it. It may be stated, that the 
presumption is strongly in favour of the latter of both 
these alternatives. It appears pretty certain, that the 
great increase of vital action among the particles of the 
blood at the inflamed part, is attended with a diminution 
•in those actions which result from vital affinities in other 
parts of the body. And it is at least highly probable, 
that the impression produced on the Nervous System, 
by the existence of this diseased state in one part of the 
body, is an important agent in the transmission of mor- 
bid change to other parts ; just as it is in the highest 
degree probable, that it is through the intervention of a 
change in the Nervous System that cold applied exter- 
nally to a distant part, or to the whole surface, comes 
to act as the exciting cause of inflammation in a single 
internal organ. And in the case of inflammation at- 
tended with spasm of the inflamed part {e. g, of Asthma 
attending Bronchitis), while we are certain that the 



140 OUTLINES OF PATHOLOGY AND PRACTICE. 



spasm is a nervous affection, we can hardly doubt that 
the two simultaneous diseased actions in the same part 
are excited through the same agent. But, in the ab- 
sence of absolutely decisive evidence, we refrain from 
speculating farther on these points. 

Sect. 111.— Of the Remote Causes of Inflammation. 

Aetee what has been already said of the causes of 
disease in general, it is unnecessary to enlarge on this 
part of the subject, but it is necessary to state which of 
the causes formerly enumerated have a peculiar or spe- 
cific effect in producing inflammation. 

Inflammation is hardly ever directly excited merely 
by muscular exertion, by external heat (unless in such 
intensity as to be a local irritant), by mental emotion, 
by such intemperance in eating or drinking as hurries 
the movement of the blood, or by such evacuations, or 
such suppression of previous evacuations, as alter the 
quantity, or even the composition of the blood ; although 
it is often aggravated or renewed by such causes. But 
it is excited by mechanical or chemical irritation (in- 
cluding Heat) applied to the part itself which inflames ; 
it is excited by Cold, applied generally, or to parts distant 
from those that inflame ; and by certain poisons, and 
certain contagions, such as arsenic or mercury, bitter 
almonds, the virus of small-pox, which are believed to 
be taken into the blood, and to visit all parts of the 
system, but afl'ect in this manner only certain tex- 
tures, chiefly the skin, the mucous membranes, and 
certain glands. And there is always ground for in- 
ferring the action of some peculiar or special cause. 



OF INFLAMMATION IN GENERAL. 



141 



if any other but an inflammatory disease is produced by 
these means. 

Of these exciting causes, no one acts with such cer- 
tainty and rapidity, as the contact with any serous, cel- 
lular, or synovial membrane, of substances which con- 
tinually pass over the mucous surfaces, with the effect 
only of exciting the due secretion of the protecting 
mucus, — air, food, bile, urine, in fact any substance 
foreign to the system, or which is elaborated in it only 
for the purpose of excretion. 

It will afterwards appear, that poisons formed in the 
course of inflammatory diseases themselves, and circu- 
lating in the blood, may excite inflammation of peculiar 
character, in other parts of the body. And it has been 
rightly stated, as a mark of distinction of those inflam- 
matory diseases, the cause of which thus exists in the 
circulating fluid, that they are apt to attack the two 
sides of the body indiscriminately, or corresponding parts 
(as the kidneys), simultaneously and similarly. 

In the natural actions of the intestinal canal, espe- 
cially when excited, and in its relations to the contain- 
ing parts, there are special causes for certain accidents, 
often acting as causes of fatal inflammation there, viz. 
Hernia and Intussusception. 

There is a class of causes which may be said to act 
on the footing of local irritants in exciting inflamma- 
tion, but which are applied, not to the parts that be- 
come actually inflamed, but to others in their immediate 
neighbourhood, or peculiarly connected with them. 
Thus various local chronic diseases, a carious tooth, a 
diseased vertebra, or joint, a strictured urethra, are very 
generally connected v^dth repeated attacks of inflamma- 
tion and suppuration in the adjoining soft textures ; and 



142 OUTLINES OF PATHOLOGY AND PRACTICE. 



inflammation, going to ulceration, on any membrane, is 
very often attended, especially in young persons, with 
inflammation of the nearest lymphatic glands. 

And again, injuries of certain nerves are followed by 
inflammation in the parts which they supply. Of this 
the best examples are the eff'ect of section of the oth 
and 8th nerve, on the eye and bronchi£e, and the ef- 
fect of section or destruction of the spinal cord on the 
mucous membrane of the urethra and bladder. In these 
cases, it would seem that the immediate efi'ect of the 
loss of power in the sensitive nerve, is the great dimi- 
nution of the mucous secretion, which is habitually re- 
gulated by sensation, and that the strictly exciting cause 
of the inflammation is the stimulus of the air, and of 
the urine, acting on a membrane deprived of its protect- 
ing mucus. We see also, in various cases of Palsy, and 
occasionally of Neuralgia, that when the sensitive nerves 
of any external part have lost their power, or been 
much injured in their functions, inflammation of the 
parts they supply, from various causes, is apt to come 
on ; just as it is apt to come upon a part of which the 
circulation has been much enfeebled, as by disease of the 
arteries, and in both cases is very apt to go to gangrene. 
It may be conjectured, that it is because, in the natural 
statef the capillary circulation in all external ^^arts, is 
much excited and maintained by their sensations and 
sensitive nerves, and therefore is enfeebled by loss of 
sensation, that inflammation of this form is so apt to 
attack palsied parts ; and if this be the true explanation, 
the injury of nerves becomes only the predispmient cause 
of the inflammation that follows it. But as we are sure 
that the exciting causes of internal inflammations act 
through nerves, we must regard it as quite possible, that 



OF INFLAMMATION IN GENERAL. 



.143 



injuries of nerves may act as strictly exciting causes of 
inflammation in the parts they supply. 

It is always to be remembered, however, that there 
are many cases of inflammation for which no adequate 
exciting cause can be detected. 

The tendency to inflammation is not in general given 
by Plethora (although the gouty inflammation occurs, at 
first, almost solely in plethoric habits), nor by habitual 
excitement of the vascular system. On the contrary, 
there are none who resist the influence of the exciting 
causes of inflammation so well, as those in whom the 
blood is abundant, and the vascular system vigorous. 
But the tendency to inflammation is remarkably given 
by all permanent causes of Debility, — by imperfect 
nourishment, impure air, long continued heat or cold, 
excessive evacuations, mental depression, excessive ex- 
ertions, and intemperance. Of the numbers who fall 
into disease, as above stated, under the influence of these 
causes, a very large proportion are always found to 
have contracted difi'erent forms of inflammation.* 

The seat of the inflammation, which may be pro- 
duced by the concurrence of any causes which do not 
act as local irritants, is determined in many cases by 
some assignable circumstances of predisposition, aff'ect- 
ing particular organs, which were formerly mentioned, 
— by various causes of local plethora or increased action, 
—by heat acting on the liver and bowels, or cold acting 
on the air-passages ; by any causes exciting the secre- 
tions of individual secreting organs more than of others, 

* Les Pleurisies les plus graves sont ces des sujets les plus de- 
biles, des cachectiques, des hommes afFaibles per des exces quelconques, 
par la syphilis, la goutte, le scorbat, le cancer, et surtout par I'age." 

— (L'XENNEC.) 



144 OUTLINES OF PATHOLOGY AND PRACTICE. 

as of tlie stomach and bowels during digestion, or of 
the breasts during lactation ; by organic diseases con- 
fining or obstructing the circulation in particular organs 
or textures; or by previous inflammation facilitating 
local congestion in the same parts as had formerly suf- 
fered. 

Lastly, the kind of inflammation excited on any occa- 
sion in the body is very often observed to be determined 
in one of three distinct ways, Firs% By predisposing 
causes previously acting on the body. Thus there is a 
hereditary tendency, often much increased by full living, 
which disposes to Gout, in circumstances where other- 
wise a different inflammatory disease might have been 
excited ; there is also a hereditary tendency, often ag- 
gravated by imperfect nourishment, by inadequate protec- 
tion from cold, and by residence in vitiated air, which dis- 
poses to Scrofulous afl*ections, rather than to other forms 
of inflammation ; there is a peculiarity of habit, often re- 
sulting from habitual intemperance, which seems to pre- 
dispose remarkably, in internal parts, to chronic inflam- 
mation, and to slow efl'usion of solid lymph and induration 
of textures. Secondly^ The kind of inflammation is often 
determined by a specific property in the exciting cause, 
— thus, that which is excited by heat acting on the surface 
of the body is specifically difl*erent from that which is 
excited there by bruises or wounds. And the inflam- 
mation excited by each of the contagious poisons, by 
gonorrhoea or syphilis, by smallpox, measles, or scarla- 
tina, erysipelas, plague, &c., has always something pe- 
culiar and specific in its own course, in its local eff'ects, 
and in the nature and progress of the accompanying con- 
stitutional symptoms. Thirdly, When inflammation 
exists in one part of the body, and is excited by any 



OF INFLAMMATION IN GENERAL. 145 



cause in another part, its progress and effects in this last 
are apparently much modified by its previous effects in 
the part first affected, as might be expected from what 
was said of the gradual alteration of the blood in the 
course of inflammation. Thus the effect of rheumatic 
inflammation in the heart, or of the secondary inflam- 
mation, connected with inflamed veins, on any internal 
part which may become affected in such a case, is rapid 
and peculiar. 

The importance of the knowledge of these facts, as in- 
structing us how inflammations may be avoided, or what 
form of inflammation may be apprehended, in indivi- 
dual cases, requires no illustration. And the influence 
of a truly Tonic Kegimen, in protecting against inflam- 
matory disease, is easily proved by statistical facts, of 
the kind formerly considered. 



Sect. IV, — Of the Local Effects^ and Anatomical 
Characters^ of Inflammation, 

In strict language, there are only two terminations of 
the state of inflammation in any part of the body, viz., 
that by Resolution, or return of the circulation there to 
its previous condition, and that by Mortification, or death 
of the part. But it has been already stated, that dif- 
ferent effusions from the inflamed vessels take place in 
almost every case of inflammation ; these effusions very 
often continue, and sometimes become the seat of farther 
morbid changes, after the inflammation has subsided or 
been resolved ; and hence, these effects of inflammation 
have often been called terminations of it j although most 
generally the resolution of the inflammation does not 

K 



14G OUTLINES OF PATHOLOOY AND PRACTICE. 



take place till some time after these effects have ap- 
peared. 

I. In regard to the termination of inflammation by 
resolution (which term is applied whenever the effusions 
from inflammation are so slight and transient as to cause 
little or no inconvenience and demand no treatment), 
several facts demand attention. 

1. In all parts of the body, and whatever other con- 
sequences may result from inflammation, the sponta- 
neous tendency to this termination is strongly marked ; 
although the time within which this tendency begins to 
shew itself, may vary from a few hours to many days 
or weeks, according to the intensity of the inflammation, 
and according to various circumstances which will be 
stated under the head of Varieties of Inflammation. 

2. When inflammation is established at any part of 
the body, it very generally extends itself more or less to 
the neighbouring parts, before subsiding ; and frequently 
the decline of the inflammation, in the part first affected, 
is follov/ed by an extension of it in the surrounding parts. 
This extension is more obvious in some varieties of in- 
flammation, to be afterwards described, than in others. 
The extension of inflammation takes place more rapidly 
along any one texture, than from one texture to another 
immediately adjoining; e. g, more readily along the pe- 
ritonseum, or mucous membrane of the bowels, than from 
either of these to the other ; more readily along the 
membrane lining the bronchise, or along the pleurae, 
than from the bronchise to the substance of the lungs, 
or from the pleura costalis outwards ; but intense inflam- 
mation may spread rapidly through various textures. 

' It is very remarkable, that in spreading over a single 



OF INFLAMMATION IN GENERAL. 



147 



texture, such as the peritonaeum covering folds of intes- 
tine, inflammation evidently extends itself, not only along 
continuous surfaces, but to surfaces adjoining to, or in 
contact with, that first affected, although not continuous 
with it, or united with it by any material bond of union. 
These facts as to the extension of inflammation are im- 
portant on many accounts, and among others because 
they illustrate to a certain degree what is seen as to 
the extension of others, and especially of what we call 
malignant diseases. 

3. In some inflammatory diseases there is a peculiar 
tendency of distant parts (generally, however, consisting 
of the same or similar textures) to become inflamed, 
and run the usual course of inflammation successively, 
as in Gout, Rheumatism, Cynanche tonsillaris, or inflam- 
mation of the Testes. 

4. In a few cases we observe a sudden and unusual 
resolution of inflammation in a part first affected, fol- 
lowed immediately by its appearance in a distant part, 
to which the term metastasis is properly applied. This 
occurs chiefly, perhaps exclusively, in the case of those 
inflammations which we shall afterwards describe as spe- 
cific^ i. e, as presenting decided marks of distinction, 
from the inflammations seen in other instances in the 
same parts or textures, e, g, in Gout, Hheumatism, Ery- 
sipelas, Gonorrhoea, Cynanche parotidsea. 

II. The first effect of inflammation in any texture, 
often perceptible in the living body, and more generally 
in the dead body, is Congestion of blood in the small 
vessels, with some effusion of the serous part of the 
blood. Where the symptoms of inflammation, during 
life, have been well marked, these appearances may in 



148 OUTLINES OF PATHOLOGY AND PRACTICE. 



some cases be all that may be found after death. But 
if no farther effects of inflammation are observed, these 
are not sufficient of themselves to entitle us to affirm 
that the part has been inflamed ; as is sufficiently proved 
by the acknowledged difficulty of judging, from such 
appearances only, even of the congestions of blood hav- 
ing taken place at any distance of time before death. 

There is probably a distinction between any appear- 
ances resulting from mere congestion of blood, and those 
of genuine inflammation in its early stage, in the colour 
of the affected parts, which in the latter case is more 
florid ; but this diff*erence is to be depended on only if the 
parts are examined within a very short time after death. 

The very early efi'usion of serum from inflammation 
is most distinctly seen in certain cases of inflammation 
affecting the skin, and in the inflammation of serous 
and synovial membranes, and of the substance of the 
lungs, where it takes place almost from the very com- 
mencement. The same eff*usion takes place behind the 
mucous membrane of the air passages, in cases of oedema 
of the glottis, consequent on inflammation there, and to 
the same cause we must ascribe the increased quantity, 
diminished consistency, and altered qualities, of the se- 
cretion of the mucous membranes soon after the com- 
mencement of inflammation in them ; and the diminished 
cohesion, or softening, from incipient inflammation, in 
these membranes, and in most of the parenchymatous 
viscera,— the brain, liver, or kidneys. When muscular 
fibres are themselves affected with inflammation (which 
is not a common case), this softening and consequent 
loss of power seems to be the chief alteration effected 
on them. Part of the swelling in inflammation of the 
cellular texture is owing to the same effusion, and there 



OF INFLAMMATION IN GENERAL. 149 



are some cases in which oedema, extending to some dis- 
tance from the inflamed part, is consequent on inflam- 
mation of the cellular texture. But the serous effusions 
of the first stage of true inflammation are more limited 
in extent than dropsical effusions, and are quickly fol- 
lowed by other exudations. No great extent of dropsi- 
cal eflPusion is ever the effect of local inflammation only ; 
although we shall afterwards find that different inflam- 
matory diseases, by the obstructions to the free move- 
ment of the blood which they ultimately produce or ag- 
gravate, frequently assist in the production of dropsy. 

III. As inflammation advances, the fluid effused from 
the vessels becomes of a thicker or more gelatinous con- 
sistence, and there is soon a distinct efi*usion of the co- 
agulable lymph of the blood, characterizing the Adhesive 
stage of the inflammation. 

This effect of inflammation is most distinctly seen in 
the formation of adventitious membranes, which are 
frequently found on the free surface of the serous mem- 
branes when inflamed, and by which the opposing parts 
of that surface, in the thorax or abdomen, are often 
united. But a similar deposit is often seen on the sur- 
face of the skin, from intense inflammation and vesica- 
tion, and often likewise succeeds inflammation of the 
mucous membranes in some parts of the body, as in the 
larynx and trachea in croup, or in parts of the great in- 
testines in dysentery. It is by a similar exudation of 
coagulable lymph on the surface, or into the interstices 
of textures, that either the membranes already men- 
tioned, or the fibrous or synovial membranes, become 
thickened and corrugated ; that the cornea becomes 
white and opaque, or the iris partially loaded, discoloured 



150 OUTLINES OF PATHOLOGY AND PKAGTICE. 



and irregular ; that the celkilar substance in any part be- 
comes dense and hard, in common phlegmonous inflamma- 
tion, and in many cases of the ery thematic also ; that the 
spongy texture of the lungs becomes mottled with reddish 
or whitish granulations, in what is usually called hepa- 
tisation from peripneumony ; and that enlargement and 
condensation of other of the parenchymatous viscera 
result from their inflammation, and precede the other 
consequences of tha.t process. Where the bloodvessels 
or valves connected with them are themselves inflamed, 
a similar exudation thickens their coats, and often lines 
part of their inner surface, and obstructs the flow of 
blood along them. And in all textures, when ruptured 
or lacerated, this kind of effusion, consequent on the in- 
flammation excited, is the most essential step towards 
the reparation of the injury. This change depends on 
the increasing proportion of the liquor sangTiiiiis which 
takes the form of Fibrin, and in this fibrinous effusion are 
there detected what have been called numerous Exuda- 
tion Globules, or Globules of Inflammation, larger and 
less regular than the globules of the blood, and many of 
which become afterwards germinating cells or cystoblasts, 
and are the seat of a vital act of nutrition, often going 
on for a long time. (See Gerber, translated by GulliveTj 
p. 79, et seq.) 

The lymph thrown out is probably always at first fluid, 
and is soft and flocculent for some time, but the serous-' 
part of the efi'usion is soon absorbed, and, if the inflam- 
mation proceeds no farther than this stage, the fibrin 
effused becomes gradually of firmer consistence, and 
soon shrinks remarkably in bulk. From this cause, 
there is frequently much hardening of various parts oi 
the body, as of the skin and other membranes, and oi 



OF INFLAmiATION IN GENERAL. ' 151 

different viscera, consequent on their inflammation, after 
it has lasted some time, and especially when it has not 
been very intense. Muscular fibres acquire a greater 
firmness and rigidity, and even an increase of bulk, from 
inflammation of adjoining membranes; but this is a 
peculiar efiect, probably depending on a different prin- 
ciple, viz., that of hypertrophy, resulting from the in- 
creased action to which they are then excited. 

In some cases, much of the colouring matter of the 
blood is thrown out with the coagulable lymph on in- 
flamed surfaces. This takes place especially in the cells 
of the lungs in peripneumony, on the serous membranes 
of the chest in certain pleurisies, and on the mucous 
membrane of the great intestines in dysentery. And in 
most cases, when the effusion of lymph has been con- 
siderable, reddish striae are seen in it after a time ; and 
these subsequently assume the appearance of small ves- 
sels, stretching across the eft\ised lymph, generally in a 
pretty straight direction, containing fluid blood, and 
communicating freely with the vessels of the teiitures 
originally inflamed. The power of forming these ves- 
sels in the lymph effused, is the vital property to Avhich 
the term plasticity has been applied. When this is the 
case, the matter effused has the appearance and proper- 
ties of condensed cellular substance, so that the ultimate 
result of this adhesive inflammation is to make this ad- 
dition to the organized textures of the body. 

There is very great variety in the length of time re- 
quisite lor these effects of inflammation to take place. 
There are many instances of intense inflammation, in 
which much solid lymph is thrown out, within thirty-six 
hours from the commencement of inflammation ; and 
cases have been quoted, in which it was thought that 



152 OUTLINES OF PATHOLOGY AXD PRACTICE. 



the vascular organization of sucli Ivmph has been effect- 
ed within that time, but in general it vrould seem that 
several days are necessary for this last process. 

It is by this inflammatory exudation of matter en- 
dowed with peculiar vital properties, ar d by the subse- 
quent organization of this lymph, that the permanent 
adhesion of sm-faces which have been inflamed is eff*ect- 
ed, — that parts, recently removed from the living body, 
may be reunited to any surface which is in the requisite 
stage of inflammation, — ^that permanent additions are 
often made, by attacks of inflammation, to the thickness 
or bulk of membranes and other textures, and that 
wounds are healed, and ulcers filled up, and all breaches 
of texture permanently repaired ; a part of the matter 
which is efi*used in these last cases o-raduallv assuminof 
the appearance and properties of the textm'e which has 
been removed. The conditions most favourable to this 
eftect of inflammation, are a moderate degree of inflam- 
mation, a medium degree of vigour of vascular action, 
seclusion from air. and the absence of all other irrita- 
tions. 

Coagula of entire blood, effused on living parts, have 
appeared in some cases to become vascular and organiz- 
ed, but certainly are in general easily absorbed again, 
and do not undergo that change nearly so readily as the 
effnsions of lymph from inflammation. 

Various facts prove, not only in the case of injurv of 
bone, but hkewise of some of the soft textures (as the 
skin and mucous membranes), that the matter which thus 
assumes the properties, and repairs the losses of the 
texture that has been injured, is thrown out not only by 
the vessels of that texture itself, but likewise in part by 
those of adjoining textm-es, which have taken on this 



OF INFLAMMATION IN GENERAL. 



153 



form of inflammation. In cases of disease it probably 
often happens, that the matter thus thrown out by in- 
flammation, instead of assimilating itself to the texture 
which has been injured, either acquires the properties of 
other textures, or degenerates into structures which 
differ from any found in the healthy body. 

IV. The next effect of inflammation is Suppuration 
or the effusion of Pus, which is at once distinguished by 
its opacity, fluidity, and yellowish-white colour, and ap- 
pears, on minute examination, to contain great numbers 
of globules, somewhat larger than those of the blood, 
and shewing as little tendency to cohere together as 
those of the blood in the living body do. 

In some instances, pus gradually mixes itself with the 
effusion of serum in inflamed parts, without other change; 
but most generally, the formation of pus is preceded 
both by effusion of serum and of coagulable lymph ; and 
the purulent effusion is bounded, beneficially as regards 
the life of the body, and more or less definitely, by the 
lymph thrown out around it, so that if the abscess form- 
ing be near the surface, fluctuation becomes perceptible 
in it ; as in the case of common abscesses in the cellular 
membrane, where the pus is formed in the centre of the 
part previously hardened by effused lymph ; or in the 
case of pustular eruptions (such as smallpox) on the skin, 
which are set on a hardened base, formed chiefly by ef- 
fused lymph. 

In the advanced stages of inflammation of the skin, 
cellular membrane, fibrous and synovial membranes, 
serous membranes of the head, chest or abdomen, paren- 
chymatous viscera, and bloodvessels, effusions of pus are 
very generally found mixed with the adhesive lymph 



154: OUTLINES OF PATHOLOGY AND PEACTICE. 



that has been thrown out, but in very various modes and 
proportions in different cases, and in inflammation of dif- 
ferent textures. On the skin and serous membranes it 
is often thrown out for a length of time, and in much 
larger quantity than the lymph ; in the substance of the 
viscera it is formed more sparingly, and when formed, 
seems to distend and narroAv the cysts of lymph by which 
it is surrounded more gradually. In the cellular tex- 
ture of the lungs it is seldom formed, in consequence of 
active inflammation, in circumscribed abscesses, but is 
gradually infiltrated or diffused through the whole in- 
flamed part. On the mucous membranes of the air- 
passages (including the tunica conjunctiva of the eye), 
and urinary passages only, it is frequently effused and 
mixed with the other secretions of the parts, even from 
simple or healthy inflammation, without any previous 
distinct exudation of plastic lymph. In all other tex- 
tures, when the effusion from inflammation is puriform 
only, it may probably be concluded that the inflammation 
is of a peculiar or specific charactei'. 

The length of time requisite for inflammation to last 
before pus is distinctly formed, varies from a few hours 
(in the case of the urethra) to several weeks. The 
length of time that suppuration, once established, may 
continue in a part, is still more various ; and the inten- 
sity of the inflammatory symptoms that may precede or 
accompany the suppuration, bears no fixed proportion to 
its amount or duration. 

When the formation of pus ceases, in a circumscribed 
abscess, the cavity is gradually filled up, partly by the 
surrounding parts that had been compressed regaining 
their previous form and bidk, and partly by the organi- 
zation and subsequent contraction of portions of the 



OF INFLAMMATION IN GENERAL. 



155 



lymph thrown out along with or after the pus, and 
which take the form of granulations. 

The effusions of adhesive plastic lymph, and of fluid 
pus, from inflammation, are very distinct in their pro- 
gress and effects, but in their origin it is obvious that 
they are very closely allied. In cases of pleurisy or 
peritonitis, detached flakes of lymph, mingling with the 
serous effusion, appear to constitute the first step to the 
formation of pus ; and in rapidly fatal cases of various 
inflammatory diseases, the glutinous exudation that is 
found, often appears to be intermediate betwixt lymph 
and pus. On the surface of the body, it has already 
been observed that the character of the inflammatory 
exudation is much determined by the circumstance of ex- 
posure to the air ; the same surface which throws out pus 
when exposed, forming plastic lymph when it is protected 
from the air, and acquires, apparently, a higher degree 
of vitality from the influence of the living and inflamed 
textures with which it is in contact. And the same in- 
fluence of exposure to air, in promoting the formation of 
pus, may be observed in comparing the effect of inflam- 
mation of the free surface of the mucous membrane of 
the urethra, in gonorrhoea, with that of the attached sur- 
face of the same membrane, which causes exudation of 
lymph, and so leads to stricture. So also that inflam- 
mation of the pleura, which is consequent on admission 
of air into the cavity of the chest, leads, more surely 
than any other, to copious purulent effusion, or empyema ; 
and in the later stages of pneumonia, if the patient live 
so long, much of the lymph thrown out into the air-cells 
appears to be converted into pus, constituting the puru- 
lent infiltration which has been described as the third 
effect of inflammation there. 



156 



OUTLINES OF PATHOLOGY AND PRACTICE. 



In those instances, and in those parts, in wliich the 
effusion of pus is not distinctly bounded and circumscrib- 
ed by effused lymph, its effect is naturally to soften the 
textures in which it occurs, as is seen especially in the 
purulent infiltration of the lungs, and in the yellow soft- 
ening of the brain; sometimes, also, in purulent infil- 
tration into the subcutaneous cellular membrane, or into 
that which unites the coats of the intestines. Such 
changes are generally the effect of a longer continuance 
of inflammation, than the softening or serous infiltration 
only ; but they denote a shorter and more violent inflam- 
matory action than the chronic induration of textures by 
effused lymph, already mentioned. That both the soft- 
ening, with infiltration of reddish or brownish serum, 
and the softening with infiltration of yellowish or green- 
ish pus, in nervous matter, are effects of inflammation, 
appears most evidently from this, that they may clearly 
and speedily result from mechanical injury. 

V. The inflammatory effusions, and especially that of 
pus, are always attended with more or less of Absorp- 
tion, first of the serum originally eff'used, and afterwards 
of the lymph which surrounds and limits the suppura- 
tion, and of part of the purulent matter itself. The 
maturation of a pustule of smallpox, or other cutaneous 
suppuration, and the enlargement of the cavity of an 
abscess, and its progress towards the surface of the body 
(the intervening textures, and ultimately the skin, dis- 
appearing to make way for it), sufficiently illustrate the 
amount of absorption which necessarily attends this effect 
of inflammation. But very frequently the absorption, 
both of the lymph effused, and of the surrounding tex- 
tures, that coexists with the advanced stages of inflam- 



OF INFLAMMATION IN GENERAL. 157 



mation, takes place in a greater degree, and more irre- 
gularly, than is requisite for any useful purpose, and the 
process is then said to be attended by Ulceration. 

The destruction of the solids of the body by ulceration 
takes place with very different rapidity in different tex- 
tures, and in different circumstances ; and it is always 
obvious, that the intensity of the preceding inflammation, 
and the extent of the other effects resulting from it, are 
by no means the only conditions which determine the 
degree of the ulceration. It is common on the surface 
of the body, both in the skin and cellular membrane, and 
common in the mucous membrane of the alimentary 
canal, — -including the fauces. It is common also in 
bones, and in cartilages that have had osseous matter 
morbidly deposited in them by an inflammatory action ; 
in the lungs, and in the inner membrane of arteries ; but 
it is not so clearly the effect of mere inflammation and 
suppuration in these cases. It takes place, in all parts 
of the body, more readily in solids recently formed by 
inflammatory exudation, than in any of the original tex- 
tures. There are some textures, again, which seldom 
ulcerate, and often resist and limit the extension of that 
process ; particularly the fibrous texture in all its forms, 
the serous membranes, and the outer coat of arteries. 
These peculiarities are often observed, and have import- 
ant consequences in disease. 

The occurrence of ulceration in consequence of in- 
flammation, is very often determined by causes which 
are sufficiently understood, especially by such as stimu- 
late and irritate parts already inflamed (as is done by the 
continued contact of any foreign body) ; and such as en- 
feeble the circulation, either generally or locally, before 
and during the excitement of inflammation. There are 



158 OUTLINES OF PATHOLOGY AND PRACTICE. 



certain specific kinds of inflammation, to be mentioned 
afterwards, in which the tendency to ulceration is greater, 
and more uniform, than in simple inflammation. 

As ulceration, consequent on inflammation, is 'very 
generally preceded by eff'usion of plastic lymph, so it is 
attended by more or less of that efl'usion which forms 
the little vascular and organized eminences, called Gra- 
nulations. When, therefore, inflammation has advanced 
to this stage, it has established three vital processes, 
which go on simultaneously, and all of which are new to 
the part that has become inflamed, — the exudation of 
plastic lymph, the eff'usion of pus, and the ulcerative 
absorption. By the irregular growth of the granula- 
tions, and the irregular or varying extent of the ulcera- 
tive absorption, the surface of an ulcer is necessarily 
rendered uneven ; and ultimately the healing of the ulcer 
is eff'ected by the process of exudation and organization 
of lymph prevailing over the contrary process of destruc- 
tion of solids. 

The degree in which these opposite processes shew 
themselves, either over the surface or in any part of the 
ulcer, admits of great variety. When the wasting by 
ulcerative absorption is most rapid, and there is little or 
no renovation of solid matter, the ulcer is said to be 
phagedwnic j when the ulceration is attended with partial 
mortification, portions of the solid textures separating 
entire from the rest, the case is one of sloughing ulcer; 
when the process goes on slowly, the lymph thrown out 
at the base and around the edo-e of the ulcer becomes 
hardened, and the granulations on its surface are defi- 
cient, and the ulcer is said to be callous^ or indolent ; 
and again, when the granulations are larger and softer 
than usual, and require to be repressed, in order that 



OF INFLAMMATION IN GENERAL. 



159 



the healing of the sore may be effected, we have the va- 
riety called the fungous ulcer. All these varieties may 
occur in ulceration following the usual and simple form 
of inflammation. 

It is in vain to attempt to ascribe any of these pro- 
cesses, consequent on inflammation, to any mode of ex- 
ertion of the contractile power of the vessels, by which 
the blood is brought to the inflamed parts. They must all 
be referred, as the healthy actions of Nutrition and Se- 
cretion must, to the influence of certain attractions and 
repulsions peculiar to living matter, and which actuate 
at once the vessels, the textures in which they are placed, 
and the blood which they contain. 

There is a very important difference between the mor- 
bid actions of Suppuration and Ulceration, once fairly 
established, and the morbid action of Inflammation not 
yet advanced beyond the earlier eff'usions of serum and 
lymph, as to the degree in which these actions depend 
on the quantity of blood that visits the parts aff'ected ; — 
the process of inflammation, in its earlier stages, being 
very certainly restrained or arrested by diminution in 
that quantity; whereas the loss of blood, although it 
often prevents the extension of suppuration and ulcera- 
tion to parts not yet aff'ected, is generally found ineffec- 
tual in checking the formation of pus, where that has 
been already established ; and is often, as may be judged 
from what has been said as to granulations, unfavour- 
able to the healing of ulcers. 

There are a few cases where inflammation (g. g. of the 
I testis, or of muscular fibres), after it has caused some 
effusion of lymph, is followed, not by the ulcerative ab- 
sorption now considered, but by a simple increase of the 
natural absorption of the part, producing mere wasting. 



160 OUTLINES OF PATHOLOGY AND PEACTICE. 



VI. The termination of inflammation in Gangrene, 
and then in complete Sphacelus, or in Mortification, is 
denoted by the part inflamed becoming gradually cold 
and insensible, and the circulation in it ceasing. This 
change generally takes place in the parts that had been 
most inflamed, while the surrounding parts are still in a 
state of active inflammation. It is usually attended 
with softness and flaccidity of the affected parts, with a 
gradual change of colour to purple and then to black, 
and ultimately with putrescence and a cadaverous smell. 
But in some cases, chiefly of slow progress, as in the 
gangrene from the use of diseased grain, the parts affected 
are hard and dry, and hardly become putrid; and in 
many cases mortification, especially when partial, is un- 
attended with blackness. Gangrene on the surface of 
the body often takes place in connexion with serous ef- 
fusion, and the vesicles formed are then coloured purple 
or black. 

Mortification is observed in consequence of inflamma- 
tion frequently in the difi'erent textures on the surface 
of the body, and in the mucous membrane of the ali- 
mentary canal, occasionally in the serous membrane of 
the abdomen, and in the substance of the lungs ; rarely 
in other internal organs, excepting in cases of inflamma- 
tion from injury. Mortification of the bones, either in 
the partial form termed Exfoliation, or in the more 
general form called Necrosis, is a common effect of in- 
flammation, especially about the central parts of the long 
bones ; but the whole process is very slow in that tex- 
ture. 

This effect of inflammation is much less uniform, in 
any texture, than the others, occurring in very various 
degrees, and at very various period??, from the commence- 

6 



1 



OF INFLAMMATION IN GENERAL. 



161 



ment of the disease, in different cases ; and hence there 
is a manifest presumption that its occurrence is deter- 
mined by other conditions in the state of the patient, 
besides the existence or the intensity of the inflamma- 
tion. Accordingly, various causes have been observed 
to increase remarkably in the disposition to this effect, 
— the general tendency of all which may be said to be, to 
weaken the circulation in the affected part. 

Thus inflammation, e. g. that from the irritation of a 
blister, at a distance from the heart, is more apt to run 
to gangrene in a feeble habit, than on the chest. The 
depending position of a part, impeding the action of 
blood from it ; a ligature compressing the veins leading 
from it, or a fibrous membrane firmly enveloping it, 
may give the tendency to gangrene from its inflamma- 
tion ; and the same tendency is often observed, if the 
arteries leading to a part are so injured by disease as to 
become rigid, and unable to maintain a vigorous circu- 
lation through it. 

The inflammation excited by a violent stroke or in- 
jury, by heat, by cold, by electricity, and by certain poi- 
sons (particularly animal poisons), is very apt to go to 
gangrene, if these causes, at the same time that they 
excited the inflammation, have had the effect of mani- 
festly weakening the circulation ; as in what has been 
called traumatic gangrene succeeding violent concussions, 
in severe burns, or frost-bite, in the bites of venomous 
serpents, and in the effects of some poisoned wounds re- 
ceived in dissection. In like manner, any inflammation, 
external or internal, which may attend or immediately 
succeed a contagious febrile disease, where the circula- 
tion is much weakened, — typhoid fever, small-pox, scar- 
latina, or measles, the worst forms of erysipelas or dy- 



162 OUTLINES OF PATHOLOGY AND PRACTICE. 

sentery, tlie yellow-fever, or the plague, — is more apt 
than other inflammations to run to gangrene. The 
same is true of inflammation on the surface of the body 
co-existing with dropsy or with palsy, when (although 
from different causes) the circulation there is feeble. 

Inflammation affecting the stomach and intestines has 
more tendency to gangrene than in any other internal 
part ; and this co-exists with the peculiar depression of 
the circulation, which characterizes the fever attending 
inflammation of these parts. 

In some instances, the tendency to this termination 
of inflammation would seem to depend on no other 
cause than unusual intensity of the inflammation, as in 
the case of the Egyptian or gonorrhoeal ophthalmia, 
tending to sloughing of the cornea, or of unusually vio- 
lent or imprudently aggravated syphilitic inflammation 
of the genitals ; but it is seldom that extensive gangrene 
can be referred to this cause only. 

When Gangrene has commenced in any part, it must 
be expected to extend somewhat, and sometimes it 
spreads very rapidly, especially when the body is under 
the influence of a powerful cause of weakness or depres- 
sion. But in more favourable cases, a line is gradually 
formed along or around the parts in the state of gan- 
grene, which feels hard, and is in a state of adhesive 
inflammation. At this line there is an effusion, first of 
serum, then of pus, and ulceration is established, by 
which a fissure is formed between the living and dead 
parts, and the latter are loosened and detached. Thus 
the adhesive inflammation, followed by suppuration and 
ulceration, sets bounds to the extension of gangrene. 
The adhesive inflammation extends to the vessels of the 
part, which are closed by lymph effused from their 



OF INFLAMMATION IN GENERAL. 



163 



coats at the point of separation of the living matter 
from the dead ; and it is to this circumstance, rather 
than to the coagulation of the blood which stagnates in 
the vessels, that we must ascribe the frequent separa- 
tion of large sloughs, without heemorrhage from the 
divided arteries. 



Sect. V. — Of the Symptoms^ Local and General^ re- 
sulting from these Effects of Inflammation, 

These may be arranged in a general view, according 
as they are local, distant, or general, over the body. 

It is unnecessary to treat of the local symptoms of 
inflammation of external parts, — whether of the true 
skin, where the redness as well as the pain, heat, and 
swelling, are obvious, and where the efiusions or other 
results of inflammation take place under the eye of the 
observer; or of the cellular or other textures imme- 
diately beneath the skin, where the redness only is con- 
cealed from the eye, and where the efiusions of serum 
and of lymph, and the gradual formation of pus, may 
in general be easily detected by the touch ; — or of the 
bones, the muscles or fasciae, the joints or bursae, where 
the peculiar form of the swelling, attended by heat and 
pain, and the kind of pressure, or of attempted motion, 
by which the pain is most distinctly excited, in general 
sufficiently indicate both the existence of inflammation 
and the texture chiefly aff'ected. It is in the interior of 
the gTeat cavities of the body that we have the greatest 
difiiculty in detecting the seat, and sometimes even in 
recognising the existence of inflammation ; yet, by care- 



164 OUTLINES OF PATHOLOGY AND PRACTICE. 



fill Observation, in great majority of cases not only the 
existence of inflammation and the organ affected, but 
even the texture in which the inflammation is chiefly 
seated, may be distinctly made out. 

The symptoms on which our attention is fixed by the 
definition of internal inflammation given by Cullen, the 
concurrence of fever with fi-xed pa2?i in some inte^mal 
part, and deranged function of some internal organ, de- 
mand the most careful study. They are of themselves 
sufficient to guide the practice, and very frequently do 
guide it almost exclusively, in the early and most re- 
mediable part of those diseases, which are more under 
the control of remedies than any others that come 
under the care of the medical practitioner : but, as each 
disease advances, more precise information as to its 
seat may very generally be obtained, and is not only 
satisfactory to the practitioner, but often important as 
regulating the details of practice. 

In such investigations the pain, although often the 
most urgent symptom, and sometimes very characteristic, 
is in general, with a view to diagnosis, the least im- 
portant part of the combination of symptoms. It is 
usually acute in the inflammation of the serous mem- 
branes, but comparatively slight, or only occasionally 
felt, when the mucous membranes (particukrly in the 
thorax), or when the substance of the viscera, the brain, 
lungs, heart or great vessels, liver or kidneys, are in- 
flamed. And the pains felt either from slight inflam- 
mation^f the parietes of the chest or abdomen, or from 
internal diseases not inflammatory, are not only equally 
or more intense than those of active inflammation, but 
in some constitutions are attended with very considerable 



OF INFLAMMATION IN GENERAL. 



165 



febrile symptoms, as we see cGiitinually in tlie head- 
achs and in the neuralgic pains, internal and external, 
of irritable subjects. 

The local symptoms which give us the most precise 
information are not only those which indicate derange- 
ment of the functions of parts, but partly also those 
which indicate alteration of the sensible qualities^ or per- 
ceptible actions, of internal parts, as modified by inflam- 
mation and by effusions ; and it is in detecting altera- 
tions of this last kind that the greatest improvements 
have lately been effected, particularly by the French 
pathologists. These have been called by some the phy- 
sical signs of disease, but this restricted use of the term 
physical is obviously liable to objection, and has not be- 
come general. Thus inflammation of the heart, or large 
arteries, not only produces palpitation — strong and some- 
times irregular pulsation — but alters the sounds heard in 
the situation of the heart either on percussion or auscul- 
tation, or both ; and in this way we can often distinguish 
inflammation and effusion on the pericardium from that 
on the inner membrane lining the heart, arteries, and 
valves. Again, inflammations of all the different tex- 
tures contained in the lungs cause hurried breathing 
and dyspnoea ; but the motions of the chest, and the 
sounds perceived in it on percussion, breathing or cough- 
ing, are essentially different, according as the pleura, 
substance of the lungs, or bronchige, are chiefly affected ; 
and these differences are of much practical importance. 

Inflammation of the mucous membrane of the bowels 
is not only attended with occasional pain and with a 
loose state of the bowels, but also (if the great in- 
testine is affected) with the excretion of altered mucus, 
often mixed with blood, distinctly characterizing its 



166 OUTLINES OF PATHOLOGY AND PRACTICE. 



nature. A similar observation applies to the inflam- 
mation of the bronchise and cells of the lungs. And it 
has only lately been ascertained that a particular form 
of inflammation of the kidneys, even when unattended 
with pain, shews itself unequivocally by rapidly in- 
creasing albuminous impregnation of the urine, which 
is of low specific gravity. It may easily be understood 
that inflammation of the brain will cause less altera- 
tion of the sensible qualities of any part of the body 
than that of almost any other organ, but the alterations 
in the condition of the eyes, and of the countenance 
generally, which often attend it, are nearly of this cha- 
racter. 

Although CuUen's diagnostic mark, the " Isesa partis 
internee functio," is very generally applicable to internal 
inflammation (as we see in impatience of light from in- 
flamed eyes, deficiency of smell from inflamed nostrils, 
various forms of delirium, or stupor, or spasm, from in- 
flamed brain, in the " vox rauca" and " tussis clangosa" 
from inflamed larynx, dyspnoea from inflamed lungs, 
vomiting of ingesta from inflamed stomach, costiveness 
or diarrhoea from inflamed bowels according to the 
membrane chiefly afl'ected, dysuria from inflamed blad- 
der, &c.), — yet it is very important to remember, that, in 
the case of those organs, the whole of which are not 
necessarily concerned in the performance of their as- 
signed functions, inflammation may afl'ect a part, while 
the function may be still so well performed by the rest, 
as to prevent any outward indication of disorder. It is 
thus that we may have partial inflammation of the 
lungs without obvious dyspnoea, especially when the 
whole quantity of blood requiring to be arterialized in 
the lungs is less than natural, — and therefore latent in- 



OF INFLAMMATION IN GENEEAL. 



167 



flammation of the lungs in feeble habits. So also the 
liver may be partially inflamed, while a sufficiency of 
healthy bile is thrown off by the sound portions ; indeed, 
it must be admitted, that both in acute and chronic 
cases any indications that we haye of altered function 
of the liver are exceedingly uncertain. And thus, also, 
inflammations of portions of the brain may take place, 
while all the functions dependent on that organ appear 
to be well performed by the remaining sound parts — a 
fact which has certainly not been allowed its due weight 
in some speculations on the uses of individual portions 
of the brain. 

Next, there may be symptoms in parts distinct from, 
although adjomi'ng to those actually inflamed, clearly 
indicating the seat of internal inflammations. This is 
sufficiently illustrated by the eff'ect of inflamed tonsils, 
or inflamed larynx, in making deglutition difficult ; or 
the very characteristic effect of inflamed peritoneum, 
in checking the descent of the diaphragm, and making 
the respiration thoracic. 

.But the most numerous of the symptoms shewing 
themselves in distant parts in consequence of internal 
inflammation, and often giying much assistance in cha- 
racterizing these inflammations, are those usually called 
sympathetic phenomena^ and of these there are two dis- 
tinct classes, the sympathetic sensations and sympathe- 
tic actions. 

The first of these are cases where, in consequence of 
inflammation in some internal part, pain is felt, distinctly 
referred to some external part — generally referable to 
known nervous communications of the two, and illus- 
trated by the pains felt at the extremities of a nerve on 
irritation of its trunk. Of this kind are the pain of the 



168 OUTLINES OF PATHOLOGY AND PRACTICE. 



right shoulder attending inflammation of tlie liver or 
diaphragm, pain at the point of the urethra attending 
inflammation of the bladder, pain at the knee attending 
inflammation of the hip joint, pain stretching round the 
thorax or abdomen attending inflammation of the spinal 
cord, pain down the spine or in various limbs attending 
inflammation of the brain. 

Again, when we see vomiting attendant on inflamma- 
tion of the brain, stomach, liver, bowels, uterus, or blad- 
der, the action of the diaphragm and abdominal muscles 
is called sympathetic, and is often a guide in the dia- 
gnosis of the disease. It depends on what has been lately 
and reasonably termed a reflex action of the medulla 
oblongata and spinal cord, with which the sensation of 
nausea is connected, certainly as a general accompani- 
ment, probably as a link in the chain of causation. And 
it is in the same manner that inflammation of the mu- 
cous membrane of the air passages causes cough, that of 
the mucous membrane of the colon, or rectum, causes 
tenesmus, and that of the mucous membrane of the blad- 
der causes strangury ; the actions of various and even 
distant muscles, in all these cases, being only an exces- 
sive degree of those sympathetic actions which are na- 
turally linked with the healthy irritation, and with the 
excited sensations, of those mucous membranes, for the 
useful purpose of the expulsion from the body of the 
excretions that pass ofl" from those mucous surfaces. 

As to the general fever which co-exists with these local 
symptoms in cases of internal inflammation, the follow- 
ing observations are important. 

1. Although in the case of simple and healthy inflam- 
mation we are accustomed to regard the constitutional 
fever as the effect of the local inflammation, still cases 



OF INFLAMMATION IN GENERAL. 



169 



are not wanting where the febrile attack, originating, 
e. g.^ from cold, distinctly precedes any local symptoms, 
and has been thought to contribute to their production. 
This is most observable in some cases of cynanche ton- 
sillaris and inflamed mamma, where the organ that be- 
comes inflamed is so situated, that if its inflammation 
had really preceded the febrile attacks, it seems difficult 
to understand how it could have escaped notice. 

2. In the more common case, where the symptoms 
of the local inflammation exist in a slight degree for 
some time before the general fever declares itself, the 
first constitutional symptoms sometimes take place very 
gradually and insidiously ; but in many cases there is a 
sudden and well-marked attack of rigors, which it is 
always very important to mark, because the sooner there- 
after that the vigorous antiphlogistic measures are em- 
ployed, the more confidence we may have in their effi- 
cacy. 

3. In early life, and in persons of sanguine tempera- 
men-t or excitable habit, the degree of febrile reaction 
which will attend any given extent of inflammation is 
much greater than in advanced life, or in persons of 
feeble habit or more phlegmatic temperament ; and in 
the former case, the febrile symptoms may often be ob- 
served to continue for a few days, after the most urgent 
at least of the local symptoms have ceased, and when 
no farther active treatment is required to cause its de- 
cline. On the other hand, a rapid and decided abate- 
ment of all the symptoms of the constitutional fever at- 
tending inflammation is always of great importance, and 
warrants a favourable prognosis, even although it be ob- 
served that the inflammation spreads, and the inflam- 
matory efl'usions increase, for a time, after that change. 



170 OUTLINES OF PATHOLOGY AND PRACTICE. 



This fact may be particularly remarked in some cases of 
plem'isy and pneumonia, and corresponds to what we see 
in cases of external inflammation, but has not been al- 
lowed due weight in recent speculations regarding the 
power of antiphlogistic remedies. 

4. Even in the same persons, the degree of febrile re- 
action consequent on inflammation seems to vary re- 
markably according to the seat of the inflammation, and 
is therefore by no means in uniform proportion to its 
extent. Inflammation of the tonsils is attended, in many 
persons, with a higher degree of fever, in proportion to 
its extent, than probably that of any other organ ; and 
the inflammation of the serous and synovial membranes 
is usually attended with more fever than that of equal 
importance in the mucous membranes, or parenchyma- 
tous viscera. 

5. Although the state of the circulation which atr- 
tends simple or healthy inflammation in its early stage 
is that which is strictly called inflammatory fever, and 
which is chiefly characterized by firm and full pulse, 
and enduring heat of skin, not easily reduced by evacua- 
tions, yet there are some instances of remarkable modi- 
fication of this febrile state. The fever which attends 
inflammation of the stomach and intestines is character- 
ized in most cases by an early and often rapid depres- 
sion of the heart's action, strongly resembling, and evi- 
dently illustrated by, the strongly sedative, sometimes 
quickly fatal, eff'ect produced on the heart's action by 
violent injuries of the abdomen. An eflect somewhat 
similar results, in many cases, from inflammation of the 
kidneys, uterus, bladder, and larger joints ; and, in all 
these cases, the peculiar sensation (a combination of 
nausea with pain) attending the inflammation, may be 



OF INFLAMMATION IN GENERAL. 171 



reasonably regarded as the medium of transmission of 
this peculiar sedative influence to the heart. 

Again, if the system has been strongly affected by 
some other influence, either previously to, or simultane- 
ously with, the excitement of inflammation, the fever 
attending that inflammation is often remarkably mo- 
dified, and may take very much the typhoid form. 
This is especially observed in the case of inflammation 
attacking a constitution in which the nervous system 
has been habitually influenced by peculiar stimuli, such 
as alcohol taken in excess ; also in the case of inflam- 
mation from an injury which gives a violent shock or 
concussion, and permanently enfeebles the heart's ac- 
tion ; and in the case of inflammation attended with the 
introduction of peculiar animal poisons into the system, 
which will be afterwards more particularly noticed. 

6. When the difl*erent effects of inflammation already 
stated have taken place to any considerable extent in 
any organ, it must be expected that the symptoms of 
the general fever attending them will undergo a change ; 
and this change of the general symptoms is always very 
important to be marked, as it generally demands a ma- 
terial alteration of the remedies employed. The nature 
of the change is different according to the organ aflected : 
in some cases, as in acute abdominal inflammation, and 
also, although at a later period, in acute pneumonia or 
bronchitis, it is mere depression of the strength of the 
heart's action ; in the case of inflammation in the brain, 
or at the heart, there is a more peculiar alteration of the 
heart's action, it becomes slow, or irregular, or preter- 
naturally strong. But the most striking and most ge- 
neral is the transition of the inflammatory fever to the 
form of hectic, which most generally attends the processes 
of suppuration and ulceration. This often begins by 



172 OUTLINES OF PATHOLOGY AND PRACTICE. 



rigors, and is marked by evening exacerbations (some- 
times two in the day), and by morning sweats with abate- 
ment, but not perfect solution, of the fever, — ^by a slight 
degree only of the thirst, anorexia, or disorder of the 
organic functions, usual in fevers, — by the absence, until 
the very last stage, of delirium, or other derangements 
of the nervous system, — by the long continuance of the 
febrile state, and progressive emaciation and debility, — 
and, towards the end of most fatal cases, by diarrhoea, 
and a florid, often aphthous, state of the mouth and 
throat, often connected with ulceration of the mucous 
membrane of the bowels, chiefly of the ilium. These 
affections of the mucous membrane seem very similar to 
those which are so apt to attend insensibility of certain 
mucous membranes from palsy or lesion of nerves. This 
state of hectic fever is much more distinctly marked in 
young and irritable constitutions than in others, and in 
such constitutions is the result of various other long 
continued diseased actions besides suppuration. 

It has been often stated, that a sudden sinking of the 
pulse, coldness of the skin, and collapse of the features, 
succeeding to inflammatory disease, are an effect and an 
indication of gangrene. But in some cases of inflamma- 
tion, particularly in external parts, gangrene takes place 
where there is no such sinking of the circulation; and 
in many cases of inflammation in all parts, e. g. in the 
lungs or bronchiee, but more particularly of abdominal 
inflammation, this sinking takes place and is fatal, with- 
out gangrene shewing itself. Such a state of the circu- 
lation, following inflammation, therefore, is to be consi- 
dered as a frequent attendant, and often as part of the 
cause of gangrene ; but not as its effect, nor necessarily 
as its indication. 

In some cases of inflammation the change which takes 



OF INFLAMMATION IN GENERAL, 



173 



place in tlie febrile symptoms in the advanced stage of 
the disease, when the inflammatory effusions have made 
some progress, is different, e, g. in inflammation of veins, 
the fever usually takes gradually the form of typhus. But 
in every case where we have any manifest alteration of 
the general febrile symptoms, combined with persistence 
of the local symptoms, whether these last indicate de- 
ranged functions, or altered sensible qualities of parts, 
we must regard the period as one of great importance 
both as to the prognosis and the practice ; indicating 
generally a state of matters in vf hich the active antiphlo- 
gistic treatment is no longer advisable. 



Sect. VI.^ — Of the varieties of Inflammation. 

Although there are many variations in the progress 
of inflammation, in different instances, which cannot be 
reduced to any general heads ; yet it is also ascertained 
that there are varieties which admit of being classified 
and generalized, and the causes of which can be assign- 
ed ; and these are of such importance as to demand a 
separate consideration, 

I. After the statements already made, it is unneces- 
sary to dwell on differences among inflammations which 
are dependent on the texture affected ; i, e. differences in 
inflammations proceeding from the same cause, especially 
from cold, and affecting different textures. 

It is sufficient to observe, that inflammation in cellular 
substance, and in the parenchymatous viscera, is gene- 
rally attended with less intense fever, and with less pain 
(unless the inflamed parts are so situated that their dis- 



174: OUTLINES OF PATHOLOGY AND PRACTICE. 



tention is prevented), than that in serous membranes, 
and that it is generally more limited in extent, and tends 
more surely to the formation of circumscribed abscesses ; 
— that the inflammation of the true skin is rapid in its 
progress, and tends especially to efl'usion of serum be- 
twixt it and the cuticle, i. e, to vesication, as is seen in 
blistering, and in the effect of burns, or of mechanical 
pressure, affecting this texture only ; — that the acute in- 
flammation of serous membranes is that which spreads 
the most rapidly, and excites the most pain and fever, 
tending first to the effusion of serum and lymph, and less 
certainly to that of pus ; and in all parts of the body, in- 
flammation of these membranes possesses these general 
characters;^ — that inflammation of the mucous mem- 
branes varies more in different parts of the body, but, in 
general, is attended with less pain or fever, spreads less 
rapidly and extensively, and tends first and chiefly to 
increase and alteration of their own secretions ; in some 
parts also, especially in the stomach and intestines, to 
ulceration. 

Again, inflammation of the investing membrane of 
bones, and other fibrous membranes and cartilages, has, 
in general, less tendency to effusion of pus than in many 
other parts ; it is slower in its progress, and tends espe- 
cially to effusion of solid lymph, often afterwards under- 
going conversion into bone, and to various alterations of 
the nutrition of the bones, to which many of these mem- 
branes are attached. Inflammation of bones themselves, 
and of cartilages, has also peculiar characters, particu- 
larly in the tendency to the formation of fresh bone, on 
the one hand, and to ulceration or sloughing (?. e. caries 
and necrosis), on the other. 

When rheumatic inflammation (which has certain 



OF INFLAMMATION IN GENERAL. 



175 



specific peculiarities not at present in our view) attacks 
different textures, it is obvious that the results to which 
it leads are determined by the nature of these textures, 
— the synovial membranes pouring out fluid effusion 
only, the sheaths of the tendons, and the pericardium, 
if it be affected, often acquiring a lining of solid lymph, 
the bones acquiring an increase of solid matter, by 
which they are enlarged and distorted, and the muscu- 
lar fibres undergoing no decided change but that of loss 
of substance and of power ; this last is indeed a texture, 
from the nutrient vessels of which inflammatory effu- 
sions perhaps never take place. 

II. Besides these differences, dependent on the tex- 
ture affected, there are others, of great importance, re- 
ferable to two heads, first, in the intensity or duration 
of the symptoms ; secondly^ in the organic changes to 
which the process leads. 

There are, firsts cases not uncommon, of inflamma- 
tion occurring in a latent form, L 6. producing its usual 
effects on the textures concerned, with so little of the 
usual symptoms, as not to be recognised, without very 
unusual care and attention, during life. 

The absence of the usual inflammatory fever, in such 
cases, is generally to be ascribed to the want of what is 
usually called Mobility or Excitability of the system, 
probably both of the nervous and vascular organs. A 
difference in this respect is remarkably observed in the 
black and white varieties of our race ; it is observed 
between aged and young subjects, and to a certain de- 
gree between persons of the lower and higher ranks. 

The absence of the usual local symptoms may very 
generally be ascribed to one of two causes, either a state 



176 OUTLINES OF PATHOLOGY AND PRACTICE. 



of debility and ansemia, in wliicli less than the usual 
quantity of blood visits the inflamed parts, or a state of 
insensibility, in which all uneasy sensations are much 
blunted. The first case is exemplified frequently in 
convalescents from febrile diseases ; the second in the 
later stage of these diseases. 

There are varieties in . the degree of intensity and 
rapidity of progress of inflammations in all parts of the 
body, which cannot be strictly defined, but are express- 
ed by the terms Acute, Subacute, and Chronic. It is 
right to distinguish the second as well as the third of 
these varieties from active and intense inflammation, 
because there are cases which are rapid in their pro- 
gress, sometimes even pretty extensive, but never attain 
any great intensity, nor require very powerful remedies 
to control them. Many such occur in various parts of 
the body, sometimes idiopathically, sometimes in com- 
bination, either with acute febrile disease (idiopathic 
Fever or Exanthemata), or with chronic disease, func- 
tional or organic ; and have had the epithet Subacute 
applied to them with more propriety than Chronic. 

The term Chronic is properly applied to those in- 
flammations which tend to the same consequences, and, 
in many instances, infer the same danger as the acute, 
but run their course much more slowly, and generally 
with less urgent symptoms. It seems necessary to 
make a deduction from cases which have been described 
as of this kind, because many such had not been seen 
by the describers at the commencement of the inflam- 
matory symptoms, and may therefore have been cases of 
the effects, or sequelae of acute inflammation inadequately 
treated, rather than examples of chronic inflammation. 
It is proper also to exclude, at present, from chronic 

4 



OF INFLAMMATION IN GENERAL. 



177 



inflammations, cases where adventitious textures are 
formed, distinct from tlie ordinary products of inflam- 
mation, altliougii there be much difficulty in distinguish- 
ing these forms of disease by their symptoms. But set- 
ting aside all such ambiguous cases, there remain a 
large number, where the usual results of inflammation, 
especially effusion of grey or yellowish lymph, and con- 
sequent induration of textures, or effusion of pus {e. g. 
into the sac of the pleura) have certainly taken place 
slowly and gradually, and often with symptoms, obvious 
indeed, but chronic rather than acute,— the local affec- 
tion being for a long time more obvious than the consti- 
tutional, and the latter consisting more in debility and 
emaciation than in febrile action. 

Such Chronic Inflammations are chiefly seen in de- 
bilitated habits, but it were a fatal error to suppose that 
such subjects are not likewise very liable to attacks of 
acute inflammation. It may perhaps be stated as a 
general fact, that on membranes chronic inflammation 
kads more to efl'usion of pus, and in the interior of 
viscera more to thickenino- and induration. 

o 

The other varieties of inflammation are those to which 
we give the name of Specific, because the effects which 
they produce are specifically distinct from those which re- 
sult from the more usual, or what we term Healthy In- 
flammations of the same parts. This peculiarity of 
effect of the process implies the existence of some pecu- 
liar cause affecting the constitution, which may be either, 
as already observed, in the previous circumstances of the 
patient, or in the nature of the specific cause of the in- 
flammation. But in both cases we have good reason to 
think, that the peculiarity of the effect of the inflam- 

M 



178 OUTLINES OF PATHOLOGY AND PRACTICE. 



mation depends on a deviation from the natural state of 
the vital properties of the blood. 

III. There is a well marked and important difference 
between the form of inflammation called Phlegmonous 
and that called Ery thematic, in external parts. The 
Erythematic Inflammation is characterized, 1. By its 
tendency to spread along the surface of the body, often 
subsiding at one part as it extends to another ; 2. By its 
colour, which is of a less vivid red than other external in- 
flammations ; 3. By its producing vesication of the sur- 
face, but little or no effusion of solid lymph ; 4. In many 
cases by the form of the accompanying fever, — bear- 
ing no proportion to, and apparently not depending on, 
the extent or intensity of the inflammation, — generally 
commencing in those severe cases, to which the name 
Erysipelas is given, one, two, or even three days, before 
the inflammation shews itself, — ^being sometimes dange- 
rous or fatal when the inflammation is slight, — -and very 
often shewing, throughout its course, more prostration 
of strength, more tendency to delirium or stupor, more 
dryness of tongue, and evidence of diminished secretion 
over the body, ^. e, a more typhoid form, than the fever 
that is simply symptomatic of inflammation does. 

In all these respects, this form of inflammation may 
be said to be specific. It differs from that which may 
be excited, at pleasure, by mechanical or chemical irri- 
tation of the surface of the body, although it often 
supervenes on injuries so excited. The body here ap- 
pears to be under the influence of a cause, which gives a 
peculiarity to the inflammation, and often likewise to the 
kind of febrile action ; and when the fever distinctly 
precedes the inflammation by one or two days, the case 



OF INFLAMMATION IN GENERAL. 



179 



is justly held to bear as mucli analogy to the febrile 
exanthematous diseases, to be afterwards considered, as 
to the inflammations. 

Accordingly, although the danger in this form of in- 
flammation sometimes depends merely on the extent of 
the local changes, and is to be obviated by moderating 
or repressing these, yet it sometimes depends obviously 
on the typhoid form, and especially on the depressing 
influence of the constitutional fever, and cannot be in- 
ferred from observation of the local inflammation, nor 
be averted by remedies apphed to that part of the dis- 
ease. 

So decided a deviation from the more usual form of 
inflammation of the surface of the body, may be sus- 
pected to depend on an external cause of local and tem- 
porary existence, rather than on causes of general ope- 
ration ; but the conditions necessary to the existence or 
efl'ect of this cause have not been fully ascertained. 
The Erysipelas has been observed to prevail most in 
confined and ill-aired situations, and to occur most com- 
monly in persons in whom the digestive organs are dis- 
ordered, or the general health otherwise impaired ; but 
it certainly cannot be referred simply to any of these 
circumstances as its cause. At certain times and places 
it prevails much more extensively than at others ; and 
at these it is certainly sometimes propagated by conta- 
gion, — ^in some instances by inoculation, and perhaps 
by this last cause more generally than is usually sup- 
posed, because, where prevalent in any situation, it is 
found to attack almost exclusively those in whom the 
cuticle has been penetrated or removed, by puncture, 
incision, injury, or blister, — a fact which suggests obvi- 
ous precautionary measures of prevention. 



180 OUTLINES OF PATHOLOGY AND PRACTICE, 



The term Phlegmon on s is applied chiefly to that in- 
flammation of external parts which ends in the forma- 
tion of circumscribed abscesses formed by dense lymph ; 
but it is also applied to any external inflammation 
which does not produce vesication, nor spread rapidly 
along the surface. 

The Ery thematic Inflammation is certainly not pecu- 
liar to the skin. In many cases it is seen to affect the 
mucous membrane of the nose, mouth, fauces and 
larynx, simultaneously with the skin of the face and 
neck, and to preserve its appropriate characters in these 
situations. In some instances it affects the fibrous mem- 
branes, especially the pericranium. It very often affects 
the cellular texture, immediately beneath the portions 
of skin which it occupies, and produces efi*ects similar 
to what it does on the surface, effusion first of bloody 
serum, and then of pus, which is in general imperfectly, 
or not at all, bounded by efl'used lymph. 

A o'ain, there is o-ood evidence, that at least in one of 
the internal serous membranes, viz. the peritoneum, in- 
flammation occasionally presents very nearly the same 
characters as Ervsi^elas on the skin, tendino- to effusion 
of bloody serum, of a whitish milky fluid, or of more 
perfect pus, with little or no exudation of plastic lymph. 
The difl'use or Erythematic inflammation in all these 
parts, may prevail epidemically, involve peculiar dan- 
gers, and demand peculiar treatment, to be noticed after- 
wards. 4 

IV. Besides the Erythematic, there are various other 
forms of inflammation aflecting the skin, and tending to 
various effects there, which are easily distinguished from 
the inflammation that is excitable at pleasure by irrita- 



OF IXFLAM3IATI0N IN GENERAL. 



181 



tion, from the erythematic form above described, and 
from each other, and which will demand consideration 
afterwards. 

There is no reason to think that inflammations of in- 
ternal parts take place in eqnallj nnmerons and definite 
varieties, as those on the skin ; bnt the Aphthae, or 
whitish crnsts often occnrring in children idiopathically, 
and in adnlts in the conrse of different weakening dis- 
eases, on the mncons membrane of th^ month and 
fances, are an example, similar to most of the cntaneous 
diseases, of slight inflammation followed by peculiar and 
long-continued effects ; and there is one form of inflam- 
mation of the mucous membrane of the fauces, almost 
equally well defined as any of the distinct cutaneous 
affections, and sometimes prevailing almost epidemically, 
— that to which the term " Diphtherite " has been ap- 
plied by Bretonneaux and others, of which the chief 
characters are, the rapid formation of flocculent aph- 
thous crusts, often extending into the lai-ynx, and some- 
times down the oesophagus, with little intensity of pre- 
vious inflammation, and with fever, slight in the com- 
mencement, and afterwards generally typhoid. The 
peculiar inflammation, beginning at parts of the gums, 
tending to rapid ulceration, and frequently to rapid and 
extensive gangrene, which occurs not unfrequently in 
weakly children, and has been described under the name 
of the Cancrum Oris, is another example of a specific 
inflammation, beginning in the mucous membrane of the 
mouth. 

Whether there is any thing equally peculiar or speci- 
fic, in the exudation, and subsequent ulceration, on the 
mucous membrane of the intestines, which often takes 
place in the course of continued fever (and has been 



182 OUTLINES OF PATHOLOGY AND PRACTICE. 



called Dothinenterite, or in that which characterizes 
Dysentery, is not so clearly ascertained. 

V. There are three distinct varieties of Inflamma- 
tion, strictly called Specific, each of which affects a va- 
riety of textures, — the Rheumatic, the Gouty, and the 
Syphilitic. 

The distinctive characters of the Rheumatic Inflam- 
mation may be stated to be, 1. That it affects different 
parts, and, in general, even different textures, within a 
short time, viz. certain fibrous membranes, probably 
muscular fibres, synovial membranes, often portions of 
the bones, and sometimes certain internal membranes, 
especially the pericardium, and membrane lining the in- 
terior of the heart. 2. That it shifts from one to ano- 
ther of these more rapidly, and more frequently, than 
any other inflammation does, insomuch that its rapid re- 
cession at one part of the body is rather a reason for 
expecting its appearance in another, than any security 
against its farther progress. 3. That, when existing 
alone, it never leads to suppuration nor ulceration, but 
to serous efliision into the articular cavities, to thicken- 
ing and induration of fibrous membranes, and remarkably 
to effusion of solid lymph on the surface of the pericar- 
dium, or on the internal membrane of the heart, when 
these are affected. From these peculiarities, it may be 
suspected that there is something peculiar in the state of 
the blood in Rheumatic Inflammation ; and it has been 
generally observed, that the fibrin of the blood in violent 
cases of Acute Rheumatism, is very abundant, and its 
separation from the colouring matter very complete. 

The Goutv Inflammation, which affects the same 
textures as the Articular Rheumatism, differs from it 



OF INFLAMMATION IN GENERAL. 183 



chiefly, 1. In affecting a much smaller number of joints 
in one paroxysm, and these generally the smaller joints 
of the extremities. 2. In being very generally preceded 
by disorders of the stomach, and often alternating with 
violent affections of the stomach, sometimes inflamma- 
tory, often apparently neuralgic. 3. In being one of the 
diseases to which a portion of mankind only is in any cir- 
cumstances liable, and in its occurrence being very often 
traced, partly to hereditary predisposition, and partly to 
particular diet and mode of life. 4. When it lasts long, 
in leading to the effusion of the peculiar tumours called 
Chalkstones, which consist chiefly of lithate of soda. 

The same matter having been lately found in the en- 
largements of bones consequent on Rheumatism, we see 
more distinctly than formerly the intimate relation of 
the two diseases. 

From the whole history of these diseases, especially 
from this last fact, and from the frequent connexion 
of gout with gravelly deposits in the urine, it is pretty 
obvious that one condition necessary to the establish- 
ment of these kinds of inflammation is, a morbid matter, 
or an excess of matter destined to excretion, elaborated 
in the system, and circulating in the blood. 

All that need be stated here as to the Syphilitic In- 
flammation, a variety undoubtedly depending on a pecu- 
liar morbid matter applied to the surface, and then mul- 
tiplying in the system and circulating in the blood, is 
what follows. 

1. It affects peculiarly the skin of the genital organs, 
the lymphatic glands in their neighbourhood, the mu- 
cous membrane of the fauces, the skin generally, the iris 
of the eye, and the periosteum and bones, at the parts 
where these are densest. 

2. It is everywhere of a chronic character, and tends 



184 



OUTLINES OF PATHOLOOT AND PRACTICE. 



to peculiar consequences— in the lymphatic glands, to 
suppuration and then ulceration ; in the skin, to various, 
but perhaps most frequently to scaly exudations, and 
often subsequently to ulceration ; in the iris, to simple 
effusion of lymph ; in the skin of the genitals and of the 
fauces, very certainly to ulceration (which ulceration, in 
the best marked and most severe cases, is characterized 
by the deep excavation and hardened base} ; in the bones, 
to irregular deposition, constituting nodes, and often to 
concomitant absorption, constituting Caries. 

It may be added, that the Syphilitic Inflammation 
and Ulceration are peculiarly under the infl.uence, in 
most cases, of Mercury acting specifically upon them ; but 
it certainly cannot be maintained, as was formerly done, 
that any form of syphilitic ulceration is absolutely devoid 
of the disposition to heal, where mercury is not used. 

It is very important to bear in mind, that syphilitic 
inflammation is often combined with, or passes into the 
form of, simple acute inflammation of the same parts, 
and often also it appears to be combined with scrofulous 
inflammation. Independently of such combinations, 
there are many varieties in the appearance and progress 
of the affections resulting from impure sexual intercourse, 
such as those designated by the names pseudo-syphilis, 
syphiloid disease, phagedoenic, pustular, vesicular, or tu- 
bercular venereal disease ; but whether these varieties 
are to be ascribed to different specific poisons acting on 
the body, or to peculiarities of constitution, is still 
doubtful. 

The poison of Gonorrhoea acts as a cause of specific 
inflammation in the mucous membrane of the urethra 
and tunica conjunctiva of the eye, which is characterized 
by rapid extension along the membrane, by copious effu- 
sion, which soon becomes puriform and capable of propa- 



OF INFLAMMATION IN GENERAL. 185 



gating the disease, and by great thickening of the mem- 
brane, bnt, on the former part at least, by total absence 
of tendency to ulceration. 

The action of Mercury on the body is a specific cause 
of inflammation in the salivary glands,— of inflamraa.tion, 
aphthous exudation, and superficial ulceration in the 
mucous membrane of the mouth and fauces, and some- 
times in the great intestines ;— and in certain persons, 
of a peculiar vesicular eruption on the skin. It seems 
also to be a frequent cause of aggravation of inflamma- 
tion, whether simple, scrofulous, or in some instances 
even syphilitic, in various parts of the body ; but it can 
hardly be said to act per se as a sufficient cause of in- 
flammation in other situations than those mentioned. 

VI. The form of Inflammation which is termed Scro- 
fulous demands a somewhat more detailed notice. 

" The term Scrofula is used by medical writers in two 
senses ; firsts to express the existence of a disease which 
possesses certain distinctive characters in whatever part 
it may be seated ; secondly^ to indicate a disposition, 
diathesis, or state, which predisposes some part of the 
body or other to become affected with such disease." ^ 

Scrofulous disease is most generally and distinctly 
characterised, either by a peculiar variety or modification 
of inflammation, and of suppuration and ulceration con- 
sequent thereon, easily recognised when the affection is 
seated externally, and known to present the same cha- 
racters in internal parts ; or else, by the formation and 
subsequent changes of those tumours, or adventitious 
textures, in various parts of the body, which are called 



Thomson on Inflammation. 



186 OUTLINES OF PATHOLOGY AND PRACTICE. 



Scrofulous Tubercles. The connexion which exists be- 
tween the scrofulous inflammation and the deposition 
and growth of these tubercles, will be considered pre- 
sently. 

There are some kinds of disorganization or organic 
disease, distinct from either of the kinds of diseased ac- 
tion above mentioned, to which the term scrofulous is 
likewise commonly and correctly applied, but which ge- 
nerally coexist with indications, either of the scrofulous 
inflammation, or of the scrofulous tubercles. 

The term Scrofulous Diathesis is applied to that pe- 
culiarity of general habit, which appears to furnish the 
great predisposition to these kinds of diseased action ; it 
being well ascertained that it is only a portion of man- 
kind that, under ordinary circumstances of exposure to 
the causes of disease, becomes affected in this way. 

The marks by which we distinguish the form of In- 
flammation denominated Scrofulous, are less peculiar and 
characteristic, than those which distinguish the erythe- 
matic, or other specific inflammations j but where ■ the 
whole course of the affection is observed, the distinction 
from simple or healthy inflammation becomes obvious. 
The common affection of external lymphatic glands is 
perhaps the best example. The pain and heat are not 
great, the colour is often nearly unchanged for a long 
time, and then is somewhat livid or bluish, the progress 
is remarkably slow, and is little influenced by remedies. 
But besides these, which may be said to denote only 
chronic inflammation, there is a more decided peculiarity 
in the suppuration, which generally follows such inflam- 
mation, lasting longer than in ordinary cases, — in the dis- 
charge being more serous, but usually mixed with frag- 
ments of curdy matter, — in ulceration very generally 



OF INFLAMMATION IN GENERAL. 187 



succeeding, and in tlie ulcers being indolent, shewing 
little disposition to heal, and often degenerating into 
fistulee. 

The following may be stated as the distinctive charac- 
ters (known from the examination of many different 
bodies, in which they exist in different stages of pro- 
gress) of Scrofulous Tubercles ; which, however, admit 
of considerable variety, both as to the mode of their de- 
position, and the changes they afterwards undergo. 

They are at first very minute, soft, or of nearly gela- 
tinous consistence, of a greyish colour, and of a some- 
what opaline lustre, have more or less of the rounded 
form, and are very often set together in clusters on the 
membranes, or in the textures, where they are formed 
( Tuber cules miliaires.) 

They afterwards enlarge considerably, several of them 
generally coalesce into one irregular mass, and they be- 
come opaque, yellowish, and of the consistence of soft 
cheese (Tubercules crus.) These tubercular masses then 
frequently soften, first in their centres, and degenerate 
into a purulent fluid, having more or less the character 
of scrofulous pus above described, some fragments of the 
solid tubercular matter floating in the fluid without be- 
coming themselves liquid. But although many tuber- 
cular masses are thus converted into ulcers, there are 
others which gradually harden into cartilaginous, and 
then into earthy concretions, and remain in an inert 
state for a very long time. The ulcers shew very little 
disposition to heal, but when they are not very nume- 
rous the discharge from them gradually abates, and they 
may become small fistulous cavities free from all dis- 
eased action. 

Appearances of simple inflammation are very often 



188 OUTLINES OF PATHOLOGY AND PRACTICE. 



found around these tubercles, many of whicli may be 
judged from various circumstances to be posterior to 
them in date, and may be ascribed in part to the irrita- 
tion resulting from tliem. 

Altliougli they undergo various changes in the inte- 
rior of their substance, at different periods after their 
deposition commences, it does not appear from injections, 
that tubercles are themselves provided with vessels, and 
hence they have been called a morbid secretion, perhaps 
more properly than an adventitious texture. "When the 
tubercular deposition is far advanced, the vessels of the 
parts affected are much obstructed, by the disease ex- 
tending to their coats, the quantity of the blood sent 
through those parts is much diminished, and the whole 
circulation in the neighbourhood much altered.^ 

These appearances are found in very different parts 
of the body, — ^according to the observations of Laennec 
nearly in the following order of frequency. The lungs, 
the lymphatic glands, the liver, the prostate gland, the 
mucous membrane of the bowels, the pleura and perito- 
neum, the testis and its appendages, the spleen, the heart, 
the uterus, the brain and cerebellum, the bones, and 
lastly, adventitious or morbid textures, with the peculiar 
matter of which they arc not unfrequently mixed. Of 
these parts, the lymphatic glands and the highest por- 
tions of the lungs are those in which tubercles most fre- 
quently originate ; and it is important to observe, that 
these are parts in which the capillary circulation must 
necessarily be very slow. 
When tubercles exist in any part in considerable num- 

* See ScHRiEDER Van der Kolk, Observationes, &c. p. 75 and 
85. 



OF INFLAMMATION IN GENERAL. 



189 



bers, they are very generally attended by much debility 
and emaciation, and, in yomig persons especially, by fre- 
quency of pulse ;. but the other symptoms connected with 
them must be expected to vary extremely, according to 
the organs in which they are formed, or the functions of 
which they impede, — according to the presence or ab- 
sence of concomitant inflammation, — and according to the 
changes which they themselves undergo. When they 
exist in those parts in which they generally suppurate, 
as in the lungs, and in the intestines and mesenteric 
glands, they are generally attended with hectic fever ; 
but this is by no means a general fact. 

The following affections, often seen in connection with 
scrofulous inflammation, or with tubercles, may be stated 
as perhaps equally characteristic of the scrofulous habit. 

1. The slow phagedoenic ulceration of the nares called 
Lupus. 

2. The conversion of the synovial membrane of joints 
into a brownish pulpy matter, seen in the most distinct 
cases of White Swelling.* 

3. Ulceration of the cartilages of the joints without 
distinct previous inflammation of the synovial mem- 
brane. f 

4. The formation of those tumours which have the 
name of Encephaloid substance, or Fungus Heematodes, 
which may exist in various parts of the body, and which 
are of softer consistence, are found in larger masses, and 
grow much more rapidly, than the scrofulous tubercles. 

In applying the general term Scrofulous to the diffe- 
rent affections now noticed, we do not, of course, mean 
to assert, that they are essentially of the same nature, 



* See Brodie on Diseases of the Joints. 



t Id, 



190 OUTLINES OF PATHOLOGY AND PRACTICE. 



altliough a general resemblance may be traced among 
them. But ^ve are induced to give this general name to 
all these affections, in consequence of our knoTring by 
ample experience, 1. That they all occur very frequently 
in persons in whom certain peculiarities of constitution, 
independent of actual disease, may be observed ; 2. That 
two or more of them very often succeed one another in 
the same individual ; 3. That they all occur remarkably 
in different individuals of the same families, while other 
families are exempt ; 4. That they are all induced or 
aggravated, and again may be confidently believed to be 
averted or mitigated, by the same or similar causes. 

No word ATOuld convey the same important meaning 
which this term Scrofula does, which should be confined 
to affections precisely of the same kind ; because what 
we wish to do, in using the term, is to mark the connex^- 
ion that subsists between different diseased actions, which 
appear, from their history, to depend on the same pecu- 
liarity of constitution, and therefore ultimately on the 
same general causes, and which may often be prevented 
or alleviated by the same general measures. 

Neither is it meant, in referring these different affec- 
tions to the Scrofulous habit or Diathesis, as their great 
predisposing cause, — to assert either that every inflam- 
mation in such a habit must be of the scrofulous charac- 
ter, or that none but persons previously of that habit, 
are susceptible of scrofulous disease. "We know that 
healthy inflammation, shewing no unusual or specific 
character, may exist, under a certain degree of excite- 
ment^ in a person already sufl'ering under scrofulous dis- 
ease j as we see in the healing of many wounds in such 
persons, and in many cases of occasional or intercurrent 
inflammation, occurring in the course of tubercular dis- 



OF INFLAiVBIATION IN GENERAL. 



191 



eases. And we know, that in certain circumstances {e. g. 
under the influence of long-continued cold, and deficient 
nourisliment, coupled witli long-continued local irritation) 
scrofulous disease may be excited in constitutions pre- 
viously quite healthy and robust. 

Nevertheless, it is important both to mark the indica- 
tions, and to generalize, as far as possible, what expe- 
rience has established as to the cause, of that habit of 
body, in which the different scrofulous affections are 
most apt to occur, and most to be dreaded. 

The chief mark of the scrofulous habit, in persons not 
yet affected with any disease, is a certain soft, flaccid 
habit of body, and especially a remarkable softness of 
skin, observed in persons in whom such a texture of the 
skin is not to be expected. The complexion is usually 
pale, with frequently a clear circumscribed redness in 
the cheek ; and this colour is easUy changed to purple 
or livid by cold. The eye has often a peculiar pearly 
lustre. The senses are usually acute, and the mental 
powers of observation and apprehension peculiarly active, 
so that children of this habit shew, in general, a preco- 
city of intellect. The scrofulous tendency is perhaps 
more frequently and decidedly seen in those who have 
fair or red hair, and blue eyes, than in others ; but is 
common in dark-complexioned persons also. 

In many cases it is more decidedly shewn by slight 
diseases, or the effects of injuries, before any serious dis- 
ease is contracted ; — by the enlarged glands in the neck 
and groins, the tumid upper lip, the chronic inflamma- 
tion of the alse nasi and membrane of the nostrils, — the 
chronic ophthalmia tarsi, or the strumous inflammation 
of the tunica conjunctiva of the eye, lasting long, with 



192 OUTLINES OF PATHOLOGY AND PRACTICE. 



little heat or redness, but much impatience of light, and 
a peculiar tendency to the formation of small pustules ; 
and also remarkably by the slow healing of slight wounds, 
the somewhat livid and chronic inflammation, and often 
the unhealthy suppuration, that succeed them. Those 
children that have the softness and consequent distortion 
of the bones, enlarged joints, and other marks of Rickets, 
are also very frequently, if not necessarily, prone to 
scrofulous disease. 

The following are the principal facts that have been 
ascertained, as to the causes by which the Scrofulous 
Diathesis, or liability to scrofulous disease, is produced. 

They may all be ranked together as causes of debility, | 
acting permanently, or habitually for a length of time, 
although not so powerfully as to produce sudden or vio- 
lent effects. 

1. The tendency is decidedly hereditary^- — L e. those 
whose progenitors have shewn marks of scrofulous dis- | 
ease, become affected in this way in much larger pro- - 
portion than others ; although it is very seldom that 
tubercles, or other scrofulous affections, are congenital. 
Feebleness of habit in parents, even independently of 
actual scrofulous disease in them, appears evidently to 
dispose to scrofula in their offspring. 

2. Although not so exclusively confined to one period 
of life, as has been stated by some, scrofulous diseases 
are much more frequent in childhood and youth, i. e, 
between the ages of two and three, and thirty or thirty- 
five, than at any subsequent period. | 

3. Although a diet almost entirely vegetable is often 
found sufficient, when other circumstances are favourable, 
for the formation of a vigorous habit of body, yet it may 

3 



i 



OF INFLAMMATION IN GENERAL. 



193 



be confidently stated, that a loiu diet habitually taken 
during youth and in health, disposes to scrofulous dis- 
ease more than a fuller diet does. 

4. The scrofulous diathesis is remarkably increased 
by the influence of cold and wet^ acting for a length of 
time on the living body ; as is shewn by the much greater 
prevalence of such diseases in the temperate or cold cli- 
mates, than in those where any applications of cold are 
comparatively transient, — and also, by the greater fre- 
quency of such affections in winter, and especially in 
spring, than in summer and autumn, in this climate. 

It is, however, a mistake to suppose, that the tendency 
to scrofulous disease cannot be formed in hot climates. 
The long-continued application of heat, in early life, is 
weakening, and therefore favourable to the formation of 
the scrofulous habit ; and it is found by experience, that 
the natives of those climates, both white and black, are 
peculiarly liable to scrofulous diseases when they come 
to the colder climates ; from which it obviously follows, 
that the rarity of scrofulous disease in the warmer re- 
gions of the globe, is the effect of exemption from its 
great external cause, — from cold of sufficient intensity, 
and more especially of sufficient endurance ; and not the 
effect of absence of the internal predisposition to such 
disease, in the inhabitants of those regions. 

Hence, although it is often of real importance to re- 
move young persons, evidently of scrofulous habit, from 
a colder to a warmer climate, at the period of life when 
scrofulous disease is most apt to occur, in order that the 
excitation of the disease at that period may be avoided ; 
yet it is a mistake to suppose, that this measure fur- 
nishes any security against scrofulous disease in future, 

N 



194 OUTLINES OF PATHOLOGY AND PRACTICE. 



if they shall return to their native climate, and be there 
fully exposed to the causes of such disease. 

Children brought up in the colder climates, if of healthy 
constitution, well fed, and duly protected from the ex- 
cessive or long-continued application of cold, acquire a 
decidedly stronger habit of body, from the habitual sti- 
mulating effect of alternations of temperature, than 
those whose other circumstances are equally favourable, 
but who are never exposed to such alternations; and 
therefore resist scrofulous disease [e. g. Phthisis) when 
the latter would fall into it ; and the natives of the 
colder climates, therefore, while they are more fre- 
quently exposed to the external cause of scrofula, have 
also at their command more effectual means, if duly 
and cautiously employed, for fortifying the constitution 
against it. 

Perhaps it may also be stated, that the exemption of 
the inhabitants of hot climates, is rather from the scro- 
fulous diseases of particular organs (especially the ex- 
ternal parts and the lungs) than from scrofulous disease 
in general ; for the chronic diseases of the Liver and 
Bowels, so common in hot climates, approach very nearly, 
in their first origin, to the distinctly scrofulous affections. 

5. The formation of the scrofulous habit is probably 
more influenced by mode of life, especially in early 
youth, than either by hereditary taint or by climate. 

It is hardly possible to observe separately the effect 
on the animal economy, of deficiency of exercise and 
deficiency of fresh air, these two causes being very ge- 
nerally applied together, and often in connexion with 
imperfect nourishment. But it is perfectly ascertained, 
on an extensive scale, in regard to the inhabitants of large 



OF INFLAMMATION IN GENERAL. 



195 



and crowded cities, as compared with the rural popula- 
tion of the same climate, firsts that their mortality is 
very much greater, especially in early life, and the pro- 
bability of life very much less (the difference being, in 
some cases, as 45 or 50 to 5, or even to 3) ; and, second- 
ly, That of this great early mortality in large towns, a 
very large proportion, generally a majority of the whole,*' 
is caused by scrofulous disease. And from these two 
facts, it evidently follows, that deficiency of fresh air and 
of exercise, are among the most powerful, and the most 
important, because often the most remediable, of the 
causes from which the scrofulous diathesis arises. 

6. It has also been frequently observed, although the 
observations have not been on so large a scale, and there- 
fore the conclusion is not so completely established, that 
the inhabitants of low moist situations are more liable, 
cceteris paribus^ to scrofulous disease, than the inhabi- 
tants of higher and more airy districts. 

7. The tendency to scrofulous disease is remarkably 
increased by habitual mental languor and depression, as 
it is counteracted by mental excitement and habitual 
pleasing emotions.f 

8. This tendency is increased by the debility succeed- 
ing great evacuations, and especially by that which suc- 
ceeds acute diseases, as fevers, or the exanthemata, or 
the febrile state excited by mercury. 

9. It is increased by any such causes as habitually 
impair the digestion, and counteracted by such means as 

* See a paper on Scrofulous Diseases by the author, in Edinburgh 
Medico- Chirurgical Transactions, voL i. 

t See a striking example in the inhabitants of a nunnery, living 
under unusual restraints, stated by Laennec, Ausc. Mediat. t. i, 
p. 647. 



196 OUTLINES OF PATHOLOGY AND PRACTICE. 

are effectual in restoring the more natural state of the 
digestive organs, and thereby the general strength. 

The effect of all the causes now enumerated is, to give 
a tendency to inflammation, however excited, to assume 
the peculiar chronic form above described, and likewise 
to predispose to the deposition, in various parts of the 
body, of the substances described as Scrofulous Tuber- 
cles, and which are the origin and foundation of the most 
formidable scrofulous diseases. 

Kow, it is obviously of the utmost importance, to 
ascertain whether, or how far, the deposition of tubercles 
is itself an effect of inflammatory action. If these de- 
posits can be assimilated to the lymph effused by inflam- 
mation, their pathology will be so far elucidated, and 
one important means of restraining their formation be 
clearly indicated. And, on the other hand, in so far as 
we can ascertain that their formation differs from the 
simple effects of inflammation, we must regard the re- 
medies for inflammation as inadequate or improper in 
the view of checking that formation. 

That the deposition of tubercles may be, and often is, 
the result of an action, to which it would be absurd to 
give any other name than Inflammation, appears to be 
sufficiently demonstrated by the following facts. 

1. Their formation may be determined in various in- 
stances by the application of the same causes which ex- 
cite inflammation. This is most unequivocally shewn 
by experiments on animals, e, g. those of Flourens on 
ducklings and chickens,* which, by being kept in a tem- 
perature somewhat less cold and more varied than that 
which excited acute pneumonic inflammation, were sub- 

* Annales des Sciences Naturelles, 1828. 



i 



OF INFLAMMATION IN GENERAL. 



197 



jected to a disease of the lungs, having the essential 
characters of scrofulous phthisis ; and those of Moulin, 
Saunders, Cruveilhier, Kay, and others,* in which 
substances, at least closely resembling scrofulous tuber- 
cles, and in some instances running nearly the usual 
course of these, were formed, in consequence of particu- 
lar modes of mechanical irritation, as by mercury dropt 
into the trachea, and acting in small quantities, but per- 
manently, on the minute vessels of the lungs. 

When we compare the results of such experiments 
with the well-ascertained fact, that masons, miners, 
needle-grinders, and other artificers, who are necessarily 
in the habit of very frequently inhaling irritating par- 
ticles, are peculiarly liable to scrofulous phthisis, w^e 
cannot doubt that this peculiarity is to be ascribed to 
the habitual mechanical irritation ; and it is reasonable 
to infer, that what is so easily excited by mechanical 
irritation of a living part, in a previously healthy animal, 
must be a product of inflammation. 

Again, there are many instances of strictly scrofulous 
local disease excited manifestly by more serious local 
injuries, and in which it appears ultimately that the de- 
position of tubercles had been the origin of the mischief. 

2. Cases occasionally occur, independent of mechani- 
cal injury, when we are very certain that the symptoms 
attending the first formation of tubercles are observed, — 
especially the cases where this deposition is much more 
general than usual, and fatal much more quickly, and 
where they are found in great numbers, very small, 
and all about the same size, implying simultaneous and 
recent deposition ; and in such cases, the remote causes, 

* See CuUen's First Lines, with Appendix by Gregory, vol. i. 
; p. 590. 



198 



OUTLINES OF PATHOLOGY AND PEACTICE. 



symptoms, and progress of tlie disease are very gene- 
rally found to be just those of inflammation of tlie same 
parts, of somewhat slower progress than is usual.* 

3. The examination of the morbid parts in cases where 
we see tubercles in their early stages, often shews scofu- 
lous tubercles not only coexisting with, but graduating 
by insensible degrees into, usual and acknowledged effects 
of inflammation, — such as flakes of lymph on membranes, 
or granulations formed by lymph effused into cellular tex- 
ture ; and the substance which has the form of incipient 
tubercles, so precisely similar to that which is thus irre- 
gularly diffused, that we cannot ascribe to them a diffe- 
rent mode or period of formation. This intimate blend- 
ing of tubercular deposits with inflammatory effusion, 
and distinct transition by insensible degrees, of the one 
into the other, is often seen on the serous membranes of 
the head, chest, or abdomen, on the mucous membrane 
of the bowels, and in the interior of the lungs or liver. 
The tubercular matter in the lungs is often, as Laennec 
states, infiltrated into the cellular texture, and when so, 
it is impossible to draw a distinct line of demarcation 
between it and the grey hepatization of the lungs. 

4. Although the changes which tubercles undergo 
after they have been deposited, are generally much slower 
than, and sometimes materially different from, those 
which take place in decidedly inflammatory effusions, 
yet in many cases they resemble those changes in their 
essential characters ; and in the case of children, in par- 
ticular (where their course is always more rapid than in 
adults), they are sometimes hardly to be distinguished 
from small abscesses, resulting from the usual causes of 

* See the papers in Edinburgh Medico-Chirurgical Transactions, 
ah'eady quoted, vols. i. and iii. 



OF INFLAMMATION IN GENERAL. 



199 



inflammation, gradually enlarging, then softening, and 
ultimately discharging purulent matter. 

From these facts, it seems reasonable to infer, that in 
certain constitutions, tubercles and all their consequences 
are direct effects of inflammatory action, and may be 
prevented if that action be arrested or subdued. 

But, on the other hand, it is plain, that there must be 
an essential peculiarity in the nature of the morbid action 
by which tubercles are formed, from these two leading- 
facts in their history, which distinguish them from the 
ordinary efl'ects of inflammation ; 1st, That they are ori- 
ginally deposited in minute but separate globules ; and, 
2(i/y, That when deposited, instead of being very liable 
to absorption (as the lymph effused by healthy inflam- 
mation is), they continue to grov/, when there is no in- 
dication of inflammation around them, and even when 
the whole quantity of blood supplying the parts where 
they exist is much diminished. And the history of many 
cases informs us, that when this constitutional peculiarity 
is very strong, little or no inflammatory action is neces- 
sary to determine the deposition of tubercles ; but that 
they will be formed wherever there is any congestion of 
blood, and sometimes where there is no vestige of pre- 
vious disturbance of the circulation. 

This tubercular diathesis may be reasonably supposed 
to depend, in part, at least, on a peculiarity in the con- 
dition of the blood ; and it is very important to observe, 
that it appears to be manifestly increased (as was ob- 
served in regard to the purulent diathesis) by tubercular 
disease already existing in any part of the body ; fresh 
deposits taking place, often in various parts, more fre- 
quently, and with much less evidence of previous disease. 



200 OUTLINES OF PATHOLOGY AND PRACTICE. 



in cases where tubercles already exist in numbers in one 
organ (e. g. in tbe lungs), tban in any other cases. 

The most leading fact that has been observed, as to 
the essential nature of tubercular deposits, and their dif- 
ference from the more diffused organizable lymph thrown 
out by healthy inflammation, is that stated by Gendrin,* 
that when examined by the microscope in their earliest 
stages, and in their distinct form, they never shew any 
of those bodies which he supposed to be decolorized glo- 
bules of the blood, which can be detected in the fibrinous 
effusions from healthy inflammation. Hence probably 
it is, that they do not form layers or flakes, as the latter 
substance does, in consequence of the peculiar mode of 
aggregation of its globules into fibres ; but that they 
gather into little separate spherical masses, under the 
influence of gravitation, as any other viscid fluid does, 
when slowly poured out in thin films, or narrow lines. 
Hence, also, in all probability, their incapacity of acquir- 
ino^ vascular oro:anization. 

All that is known of the conditions under which scro- 
fulous tubercles usually originate, may perhaps be com- 
prised in the proposition, That the blood is unusually 
serous, which implies that its vitality is of a lower grade 
than natural, because it is by a vital act only that the 
liquor sanguinis is divided into serum and fibrin ; — that 
from the same cause, its motion is languid in numerous 
small capillaries, and partial exudations of its albumi- 
nous portion are apt to take place, and cohere together 
into minute spherical masses, which are destitute of the 
power of acquiring an organized structure themselves, 

Hist. Anat. des Inflammations, t. ii. p. 595. 



il 



OF INFLAMMATION IN GENERAL. 



201 



but grow by attracting to tbemselves fresh matter from 
the vessels ; and that this exudation, although not ab- 
solutely dependent on, is much promoted by, congestion 
of blood, or inflammation, tending, by reason of the pe- 
culiarity of the blood to this kind of effect, in the parts 
where it takes place. 

All these statements, made in the first edition of this 
work, are substantially confirmed by subsequent micro- 
scopical observations, especially the following : — " Albu- 
minous or unorganized tubercles (which with great pro- 
priety are called Scrofulous Tubercles) can only be 
produced from exudations abounding in albumen, poor 
in fibrin. They consist almost entirely of granules^ from 
the losgt^ g^^th of a Paris line in diameter {i, e. 

generally much smaller than the globules of the blood), 
but with this granular matter, nucleoli, nuclei, or cells, 
are mingled in quantity bearing relation to the amount 
of fibrin which the exuded fluid contained." {Gerher^ he. 
cit. p. 305-6.) " Granular matter is the most prevalent 
ingredient of tubercles, almost always mixed with the 
other constituents, and frequently forming nearly the 
entire mass of caseous tubercles." " Corpuscles, more or 
less globular, or oval, are seen in theni, but the granular 
matter preponderates as the tubercular mass increases. 
Cells may be recognised in the miliary tubercles, but as 
they increase in size the well-marked and complete cells 
disappear. Tubercles appear to differ essentially from 
the plastic exudations, inasmuch as the cells of the latter 
not only grow into a higher organization, but increase 
in number towards the centre ; in other words, plastic 
matter has an inherent power of multiplying and evolv- 
ing organic germs ; but tubercle has no such power ; for 



202 OUTLINES OF PATHOLOGY AND PRACTICE. 



it would appear that its primitive cells can only retro- 
grade and degenerate." (Gulliver, in App, to Gerber^ 
p. 87, and figs. 252-5, and 270-71.) 

As we now know, that the peculiar properties of fibrin 
are necessary to retain the blood in the capillary ves- 
sels, we can easily understand, that exudation of the al- 
buminous granular matter, constituting most part of 
tubercles, should more easily take place from blood 
" poor in fibrin," than the exudation of fibrinous effusion 
from more healthy blood. 

Hence the practical objects in cases of Scrofulous dis- 
ease may be stated to be, first, To improve this morbidly 
defective state of vitality in the blood j secondly, To 
avoid causes of congestion of blood or inflammation in 
such subjects ; thirdly. When inflammation occurs, to re- 
strain it by early but moderate antiphlogistic treatment. 

Sect. VII. — Of the modes of fatal termination of In- 
fiammatory Diseases. 

In order that the Pathology of this or any other dis- 
eased state may be satisfactory, and susceptible of useful 
practical application, it is evidently necessary that we 
should understand, not only the changes that take place 
in the organs aff'ected, and the way in which they are 
eflected, but also the manner in which these influence 
the actions of the system at large, and ultimately extin- 
guish life. 

It is to be observed, however, that none of the fatal 
terminations of inflammation are inevitable ; when the 
effects which lead to them have already commenced, 



OF INFLAMMATION IN GENERAL. 



203 



there are still provisions of nature by wliicli all of tliem 
may be arrested ; it is by tbe degree, not by the mere 
existence of these effects, that the fatal event is always 
determined. 

I. Inflammation is sometimes quickly fatal, independ- 
ently of any alteration in the texture of the inflamed 
part, simply by the gradual depression of the powers of 
the circulation which attends it, and which may be called 
a strictly sympathetic efl'ect. The case of inflammation 
of the Peritoneum is the best example of this danger. 
The efl"ects of this inflammation, perceptible on dissec- 
tion, bear no fixed proportion to the intensity or rapidity 
of the symptoms ; and the disorganization which is found, 
efl'usion of serum, of lymph, or of pus, thickening of the 
membrane, even gangrene of the membrane (which is 
more rarely found), although they may explain torpor 
of the intestines, aff^ord no explanation of the gradual 
but rapid depression and ultimate extinction of the 
heart's action, and consequent coldness of the surface ; 
otherwise than by reference to the principle already ex- 
plained, that any violent injury of the abdomen, by vir- 
tue probably of the intense and peculiar sensation it ex- 
cites, acts as a powerful sedative on the heart. 

It is in this manner almost exclusively that inflam- 
mation of this part produces death, and it afl'ords the 
best example of death beginning at the heart, and un- 
complicated with simultaneous aff'ection of the brain, 
which occurs in any disease. 

Inflammation of the Mucous Membrane of the great 
intestines, producing the symptoms of Dysentery, whether 
going on to ulceration or not, is almost always attended 
with more or less of the sedative efl^ect on the circulation, 



204 OUTLINES OF PATHOLOGY AND PRACTICE. 



which is so strikingly exemphfied in the Peritonitis ; 
and this is apparently the chief reason of dysentery hav- 
ing been ranked with putrid, rather than inflammatory 
diseases, by the older pathologists. 

Inflammations of the kidneys, bladder, uterus, and 
larger joints, may be fatal on the same principle, without 
any such visible efi<ect resulting from them, as can im- 
pair the functions of the organs essential to life, and be- 
fore there is time for any exhausting process of suppura- 
tion or ulceration to be established. And although in- 
flammation of the liver generally leads to decided dis- 
organization before it is fatal, yet it may often be doubt- 
ed, whether the change efl'ected on that organ is adequate 
to explain the course of the symptoms, and the fatal 
event, otherwise than on the same principle. 

II. Inflammation is sometimes fatal by reason of the 
Serous Eff'usions consequent on it, impeding and ob- 
structing the functions of parts essential to life. This 
may happen especially in three situations. 1. When 
inflammation of the brain, marked by the symptoms of 
phrenitis or acute hydrocephalus, leads to such efl'usion 
into the ventricles of the brain as causes fatal Coma. 
2. When inflammation of the mucous membrane of the 
larynx produces oedema of the glottis, and consequent 
Strangulation. 3. In the rare case, where inflamma- 
tion, attacking both lungs at once, is fatal in its earliest 
stage, before any other consequence than serous efl'usion 
into the cells of the lungs has taken place, but that has 
been so general as to disqualify the lungs for their func- 
tion, and cause death by Asphyxia. 

In all these cases there is a difficulty in assigning in- 
flammation as the cause of death, where nothing but se- 



OF INFLAMMATION IX GENERAL. 



205 



rous effusion is found on dissection ; nor are we justified 
in doing so, merely from tlie appearances in the dead 
body. In merely chronic cases, great effusion into these 
parts may take place independently of inflammation ; and 
in the case of effusion within the cranium, not only when 
the sutures yield and the head is gradually enlarged, but 
when there is no such enlargement, we know, that the 
greatest accumulations of serum, and distention of the 
ventricles, are exceedingly slow in their progress ; and 
are unattended, at least during most of their progress, 
with inflammatory symptoms during life, or any decisive 
indications of inflammation after death. 

It is therefore always by a comparison of the serous 
effusion found in the parts above mentioned after death, 
with the causes, duration, and progress of the symptoms 
before death, that we judge such effusions to be inflam- 
matory. When we find, e, g, such effusion into the ven- 
tricles of the brain, as, if taking place within a few days, 
must necessarily imply much pressure on the brain, and 
explain a fatal coma, equally as effused blood or depress- 
ed bone does, — preceded by violent symptoms of a few 
days' duration, — and these symptoms just the same as 
are seen in other cases, where, on dissection, not only 
serum, but pus and lymph are found effused on the 
brain, — we cannot hesitate about regarding the serous 
effusion also as a result of inflammatory action. And in 
fact, in many of the cases to be mentioned under the 
next head, where lymph or pus are effused into the brain, 
air-passages, or lungs, the fatal coma or asphyxia cannot 
be ascribed to them alone, but must be held to be in 
part the effect of the concomitant effusion of serum. 

III. In many cases, inflammation within the Head or 



206 OUTLINES OF PATHOLOGY AND PRACTICE. 



Chest, has such distinct and unequivocal effects as satis- 
factorily explain death by Coma or by Asphyxia. 

1. The different forms of inflammatory effusion on 
the surface or in the substance of the brain, whether at- 
tended with bloody effusion into the substance, or serous 
effusion into the ventricles or not, are held to be suffi- 
cient to explain not only convulsions, delirium or palsy, 
but stupor and death. For although it be true, as for- 
merly stated, that these and other injuries of the nerv- 
ous matter, superior to the medulla oblongata, do not 
necessarily imply any such consequences ; and although 
the inflammatory action which produces these effects 
may take place with very various degrees of rapidity, 
and be attended with a considerable variety of symptoms ; 
yet it is evident that when it does take place rapidly, it 
must naturally make such an impression on the sub- 
stance of the brain, and such a change on the circulation 
there, to some distance from its own seat, as may effec- 
tually disqualify it for its function. And it is known by 
sufficient experience, that when the general symptoms 
of inflammation, and the particular symptoms of de- 
rangement of the functions of the brain, have occurred 
with violence, and advanced rapidly to coma and death, 
these appearances, and these only, have often been found 
on dissection. 

Induration of portions of the brain from inflammation 
is sometimes likewise the chief cause, which appears on 
dissection for fatal coma ; but the progress of such cases 
is generally so slow, that they are to be regarded rather 
as on the footing of organic diseases connected with al- 
teration of the nutrition of these parts, than as the re- 
sults of inflammation simply. 

2. When the Pericardium is inflamed, there often re- 



OF INFLAMMATION IN GENERAL. 



207 



suits sucli an effusion of serum loaded with flakes of 
lymph, — or of soft but concrete lymph almost without 
serum, — or subsequently of purulent matter, as necessarily 
impedes and alters, and within a time admitting of great 
variety (from forty-eight hours to several weeks), finally 
suppresses the action of the heart. But as, in such cases, 
the functions of other parts, and especially of the lungs, 
naturally suffer likewise, the death from this cause sel- 
dom takes place so distinctly and simply in the way of 
Syncope, as in other cases of inflammatory diseases al- 
ready noticed, where the affection of the heart is truly 
sympathetic. 

3. When the mucous membrane of the Larynx and 
Trachea is severely inflamed, there is always reason to 
apprehend rapidly fatal Asphyxia, either from an effu- 
sion of lymph forming a preternatural membrane, ob- 
structing the glottis, and sometimes stretching down to 
the bronchise (which occurs chiefly, though not exclu- 
sively, in young children), or from effusion of pus be- 
hind the membrane at the glottis, or even from mere 
inflammatory thickening of the membrane (with or with- 
out the serous infiltration already noticed) at that, which 
is the narrowest part of the large air-passage ; and si- 
milar results occur in some instances from inflammation 
and suppuration of neighbouring parts, pressing directly 
or indirectly on the rima glottidis. 

4. When the lining membrane of the Bronchiee is 
inflamed, an increased secretion of mucus, often chang- 
ing gradually to the puriform appearance, necessarily 
results ; and although this may go to a great extent and 
last very long without danger, yet it becomes certainly 
dangerous, and may even cause rapidly fatal asphyxia, 
by the obstruction it gives to the access of the air to the 



208 OUTLINES OF PATHOLOGY AND PRACTICE. 



blood, ill two ca?es. — -nrst. when it occurs iii a feeble 
habit, — as in the very old or the verv vouno-. or in the 
course of weakening diseases, when expectoration is dif- 
ficult and imperfect : and. secondly, when it occurs (as 
seldom happens in i<iiopathic cases) generally in both 
lungs, and extends every where to the minute branches 
of the bronchiee. 

5. When the substance of the Lungs is extensivelv 
inflamed, the effusion into the air-cells of lymph, more 
or less colom-ed by the red matter of the blood, and 
tending more or less rapidly to conversion into purulent 
matter, must be expected to cause such impediment to 
the arrerialization of the blood, as to threaten death bv 
asphyxia within a few days. 

6. When the Pleura is infiamed pretty generally on 
one side of the chest, it often happens that the fluid ef- 
fused into its sac. and which gTadually assumes the cha- 
racter of pus, becomes so abundant as to compress the 
lung of that side to such a degTee ^although with verv 
various rapidity), as to disqualify it for its function; 
and threaten death by asphyxia. 

In both these last cases there is a difficulty as to the 
reference of death to the inflammatoiy effusion compress- 
ing or obliterating the cellular structure of the lung's, 
from the observation of the great variety in the amount 
of effusion foimd after death in different individual cases : 
the portion of the lungs left fit for their functions beino' 
in some cases much smaller than in others, — whereas 
the danger fi'om this cause might, on first consideration 
of the subject, seem to be just in proportion to the 
amount of obstruction of the air-cells. 

But this difiiculty is removed if we attend to the fol- 
lowino; considerations ; jirst, that in cases where the 



OF INFLAMMATION IN GENERAL. 



209 



whole quantity of blood in the body is less than usual, 
there is less occasion for a large amount of healthy lung 
to arterialize this blood, than when the full quantity of 
blood circulates in the vessels ; secondly^ that when a 
portion of lung is gradually rendered unfit for its office, 
the blood of the pulmonary artery, as injections demon- 
strate, is gradually diverted from the diseased portion, 
and directed to the healthy parts ; * thirdly^ that in 
many cases the effects of peripneumony and pleurisy, 
now in question, are combined, either with each other, 
or with other causes of asphyxia already mentioned. 

Indeed several of the different causes of the fatal ter- 
mination of inflammatory disease of which we now treat, 
are often and very variously combined in different indi- 
vidual cases. 

IV. There are cases in which inflammation is fatal, 
apparently by reason of some part of the effusions to 
which it gives rise, being mixed with the blood, and 
acting on the footing of a Poison. Thus, when in- 
flammation is excited in a spot on the surface, by the 
application of a specific poison, as by a wound in dis- 
section, it is speedily attended by the formation of a 
similar poison, which is evidently absorbed, and excites 
fresh inflammation in the line of its passage into the 
mass of the blood ; but this inflammation is attended by 
a peculiar typhoid fever, in which the heart's action is 
rapidly depressed, which bears no fixed proportion to the 
extent or intensity of the inflammation itself, and by 
which death may take place without visible injury of any 
vital organ ; sometimes before the inflammation has ad- 

* See Sclirgeder Van der Kolk, Observations Anat. Pathol, p. 66. 

O 



210 OUTLINES OF PATHOLOGY AND PRACTICE. 



vaiiced beyond its first stage, * and generally long before 
it has gone so far as in the more usual inflammations of 
the same parts. 

Again, in the case of inflammation of the lining mem- 
brane of a Vein, it is ver]^ often observed that the ac- 
companying fever soon takes a similar typhoid form, 
often with vomiting and purging, always with a feeble 
or depressed state of the heart's action, as well as de- 
rangement of the nervous system. In many such cases, 
this typhoid form of the fever, rather than any effect 
which we can ascribe to the inflammation itself, appears 
to lead to the fatal termination ; in like manner, as a 
similar combination of typhoid symptoms does, when oc- 
curring idiopathically, or as a part of a malignant conta- 
gious febrile disease : and this peculiarity of inflamma- 
tion of this part has been ascribed to the necessary ad- 
mixture of much of the inflammatory effusion with the 
circulating blood, with more probability than to any 
other cause. 

Y. In many cases, the fatal termination of inflamma- 
tory diseases cannot be ascribed to any mechanical or 
even vital agency of products of the local disease, but is 
effected by gradual exhaustion of the vital powers dm'- 
ing the processes of Suppuration, and of Ulceration or 
Sloughing, when a new excretion is established from 
the body, and at the same time the processes of digestion 
and assimilation are greatly deranged by the constitu- 
tional fever. In such cases, death takes place rather 
by syncope than by coma or asphyxia ; but often after 
so slow a process as to resemble more the death by fast- 

* See Travers on Constitutional Irritation. 



OF INFLAMMATION IN GENERAL. 211 



ing than that by concussion, or by any injury directly 
depressing the heart's action. Extensive suppuration in 
any part of the body is sometimes followed also by rapid 
secondary inflammation and effusion of pus in internal 
organs, chiefly the lungs and liver, causing death, as 
primary inflammation of the same parts would do. This 
is chiefly to be apprehended in two cases, 1. When a 
vein has been inflamed at the part ; and, 2. When a long- 
suppurating surface has been removed by amputation, 
and there has been little purulent discharge from the 
wound inflicted. The febrile symptoms attending sup- 
puration and ulceration have usually the form of hectic ; 
those which attend gangrene are more rapid in their pro- 
gress, and more typhoid in their character ; but it has 
been already observed, that these last are very generally 
to be ascribed, in part, to some other cause, acting simul- 
taneously with the inflammation, and depressing the 
vital power. 

It is by the gradual exhaustion consequent on the 
concomitant fever, rather than by local changes, that 
inflammation of the surface of the body, of the extremi- 
ties, and organs of locomotion, is dangerous or fatal ; and 
the danger attending inflammation and suppuration of 
some internal viscera, as the liver, spleen, kidneys, and 
mucous membranes of the intestines, is generally of the 
same slow gradual kind. 

VI. Inflammation often leads, more indirectly, to a 
fatal termination, by gradually passing into, or blending 
itself with, other modes of diseased action, which de- 
mand future consideration, and aggravating the danger 
to which they may respectively give rise. Local inflam- 
mations of certain parts, and of a peculiar character. 



212 OUTLINES OF PATHOLOGY AND PRACTICE. 



very often attend botli idiopathic fever and febrile ex- 
anthemata, and constitute great part of the danger of 
these diseases ; and it is generally allowed that inflam- 
matory action sometimes gives origin to, and often com- 
bines itself with, almost all the chronic diseases to 
which the living body is subject at various periods of 
their progress, and especially with those which imply 
the gTeatest danger, viz. those which consist in perver- 
sion of the nutrition, and increase of the exhalations of 
various textures, or what are usually called Organic 
Diseases, and Dropsies ; and the combination is fre- 
quently fatal, where either affection existing separately 
might subside, or pass into a more inert or less dange- 
rous form. This kind of danger is, of course to be ap- 
prehended chiefly when the causes of inflammation are 
applied, either simultaneously with those of other dis- 
eases, or to persons in whom chronic diseases, or a 
strong predisposition to them, already exist. 

As we know that the products of unequivocal inflam- 
mation admit of considerable variety, and that lymph, 
effused by inflammation, may subsequently undergo con- 
version into various kinds of substance, it is evident that 
any kind of adventitious texture that may be formed in 
the body may originate in inflammatory action, and that 
it is possible for inflammation to give rise to every kind 
of organic disease. But on the other hand, as we know 
that the l}T[nph which is thrown out by simple and 
healthy inflammation remains for an indefinite time 
quite inert, and undergoes gradual absorption, after 
that inflammation has subsided, it is clear that some ad- 
ditional morbific cause acts, whenever inflammatory 
effusions change their form, and especially when they 
increase in bulk, after that period ; and many observa- 



OF INFLAMMATION IN GENERAL. 213 



tions shew, that, where such morbific cause exists, very • 
httle inflammatory action is required to give origin or 
continuance to the growth of adventitious textures, and 
the phenomena of organic disease. 



Sect. VIII. — Of the Treatment of Inflammation, 

We here state, first, the essential parts of the anti- 
phlogistic treatment, by which the course of inflamma- 
tion, if early opposed, may in most cases be so modified 
as to be divested of danger, and in all cases be moderated 
or restrained ; and afterwards the limitations and modi- 
fications of this kind of treatment, which are demanded 
by various contingencies in the course of inflammatory 
diseases. 

We speak first of the antiphlogistic treatment proper 
to be adopted, to a greater or less extent, in the early 
stage of all cases of simple or healthy inflammation, 
occurring in a sound constitution, and attended with 
constitutional fever. This kind of treatment consists of 
two parts, the Antiphlogistic Regimen and Remedies. 

The object of the antiphlogistic regimen is simply to 
remove every excitement or irritation which may aug- 
ment either the strength or frequency of the heart's 
action, or promote the flow of blood towards the affected 
part ; it being perfectly ascertained by experience, and 
indeed easily understood, whatever doubts we may en- 
tertain as to the rationale of inflammation, that when 
that state exists in a constitution otherwise healthy, it 
is aggravated by whatever promotes and accelerates the 
flow of blood to the affBcted parte 



214 OUTLINES OF PATHOLOGY AND PRACTICE. 



Hence the strict antiplilogistic regimen consists es- 
sentially of three parts, loiv diet, rest, and quietude. 
The abstraction, in the most urgent cases, of all solid 
aliments, in all cases, of animal food, and the denial of 
all fermented or spirituous liquors, imply a gradual di- 
minution of the quantity of the blood, and the removal 
of stimuli, by which the heart's actions are obviously 
and strongly excited. The cessation of all vigorous 
or sustained muscular movement likewise removes a 
cause by which the circulation is often powerfully ex- 
cited. The effect of muscular exertion on the heart's 
action does not seem to be satisfactorily explained by 
the mere acceleration of the flow tov/ards the heart 
by the veins ; and is probably chiefly dependent on the 
principle stated by Miiller, that the contractions of 
the heart, although not excitable directly by the wall, 
are liable to affection by those changes in the nervous 
system, which attend efforts of volition acting on the 
voluntary muscles which have their nerves from the 
same branches as the heart ; — as is undoubtedly the case 
in regard to the iris, not moveable by the will, but 
moving in concert with the recti muscles of the eye 
when strongly excited through the third pair. The ex- 
clusion of all sudden and strong impressions on the or- 
gans of sense, secures the body against a set of irrita- 
ting causes, which act primarily on the nervous system, 
but always more or less excite the vascular system like- 
wise, and very frequently, by preventing sleep, mani- 
festly aggravate the fever which is consequent on in- 
flammation. 

With the same general intention, various more parti- 
cular precautions are of importance in the inflammation 
of individual organs in all cases, the removal of any 



OF INFLAMMATION IN GENERAL. 215 



exciting cause of inflammation wliicli can be detected, 
— the horizontal position and absolute rest of an in- 
flamed limb, to retard the afilux of blood to, and favour 
the reflux from, the part afl'ected, — the erect posture, 
when the head, or any part of it, is inflamed ; the pro- 
hibition of all eflbrts of voice when the lungs or other 
organs of respiration are inflamed j the contact of soft 
substances only with inflamed portions of the surface ; 
the injunction of darkness and silence in inflammations 
of the eye and ear, &c. Under these precautions, the 
body in general, and the affected parts in particular, are 
placed in circumstances the most favourable to the gra- 
dual and spontaneous decline of inflammation. 

Of the antiphlogistic remedies^ which next demand 
consideration in all cases of inflammation, the only one 
on which absolute reliance can be placed is Bloodletting, 
and there is no other remedy for any other kind of dis- 
eased action, which can be put in competition with this 
in efficacy or importance. 

The efficacy of bloodletting in lessening the extent 
and intensity, and often virtually arresting the progress 
of inflammation, would appear to depend on two princi- 
ples, which it is important to consider separately, to 
which indeed the powers of all other antiphlogistic re- 
medies may be ascribed, — -first^ that it weakens the 
heart's action ; and, secondly^ that it causes a derivation 
of blood from the aff'ected parts. In both ways it di- 
minishes the quantity of living matter in which the pe- 
culiar changes comprised under the term inflammation 
are going on; and whatever be the precise nature of 
these changes, as it is certain that the blood is an agent 
essentially concerned in them, it is easy to understand 
that the greater the quantity of blood sent to the aff'ect- 



216 OUTLINES OF PATHOLOGY AND PRACTICE. 



ed parts in a given time, the greater amount of these 
changes, and particularly the greater quantity of effu- 
sion from the vessels (with which we have seen that the 
danger of most inflammatory diseases is very much con- 
nected) will take place. 

1. That the heart's action should fee weakened by the 
abstraction of the stimulus, by which its motion is 
habitually excited and maintained, is quite in conformi- 
ty with all that we see of the effect of loss of blood in 
the healthy state, and with the general doctrine of Irri- 
tability as laid down by Haller. It is not necessary 
in every case of inflammatory disease, nor even in every 
case of such disease w^here the heart's action is morbidly 
excited, to resort to this remedy ; because there are 
many such cases, where the history of the disease that 
exists is well known, and no danger is to be appre- 
hended from allowing the inflammation to run its 
course, under the proper regimen, and spontaneously 
decline; and there are many others, which are complex 
cases, and where the local inflammation is not to be re- 
garded as the chief danger. But in all those cases 
where not only the heart's action is increased, the pulse 
morbidly frequent, or strong, or both, — but where we 
are satisfied that this increased action is connected with, 
or maintains and aggravates, a local inflammation, 
threatening, in some of the modes already consider- 
ed, the life of the patient,- — such bloodletting as may 
impair the power of the heart is the appropriate and 
effectual remedy ; and in all cases occurring in patients 
beyond the age of three or four (below which age 
leeches are to be regarded as a general evacuation), the 
simple and effectual mode of bloodletting is by venesec- 
tion. 



OF INFLAMMATION IN GENEKAL. 217 



The effect of this remedy on the heart's action is 
by no means exclusively produced, by withdrawing a 
part of the stimulus of blood, habitually acting on the 
heart. The difference, daily observed, of the effect 
of bloodletting in the erect and the horizontal posture, 
clearly shews that the loss of blood may powerfully 
affect the heart through the intervention of the cen- 
tral portions of the nervous system, probably of the 
medulla oblongata especially, although in common lan- 
guage, we speak of this effect being produced through 
the brain. The proof of this is, that when blood is 
drawn in the erect posture, so that the influence of 
gravitation co-operates with that of the operation in 
weakening the flow of blood to the head, not only 
are the sensations and consciousness of the patient, — 
i. e. the functions of the brain and medulla oblongata, — 
much sooner aff'ected, but the heart's own action is 
much sooner impaired, than when the same quantity is 
taken from a patient lying horizontally. A most re- 
markable diminution of the frequency of the pulsations 
is thus very frequently effected, the pulse falling, for 
example, from 120 to 60 in a minute, at the same time 
that faintness and transient insensibility are produced. 
This plainly implies that the sudden diminution of the 
pressure of the circulating blood on the brain and me- 
dulla oblongata has acted or reacted on the heart, — in 
a way perfectly illustrated by many other facts ; ^by 
the failure of the heart's action, often seen to have 
been produced by taking off the pressure of depressed 
bone, or effused blood, or effused serum (as in tapping 
hydrocephalic children), to which the brain had pre- 
viously been accustomed ; — by drawing off the serum 
of ascites, and so diminishing the pressure on the 



218 OUTLIXES OF PATHOLOGY AXD PEACTICE. 



branches of the abdominal aorta, promoting the flow 
there, and proportionally lessening that towards the 
head, — or more simply by merely assnming the erect 
posture suddenly after long stooping. The decided im- 
pression made on the heart's action in all these cases 
by sudden diminution of the pressure of the blood on the 
brain and medulla oblono-ata, is in fact very analoo-ous 
to that produced by a sudden concussion, in cases of in- 
jury, or sudden increase of the pressure on these parts, 
in experiments on animals. 

This sudden and peculiar effect of bloodletting on the 
heart's action, being produced through the intervention 
of the nervous system, is of course liable to modifica- 
tion from the condition of that part of the living body ; 
and it is a just and important observation of Dr Marshall 
Hall, that the effect of bloodletting in the erect posture 
often gives an indication of the cases in Avhich the full 
use of the remedy is likely to be important : because, iu 
many diseases, not strictly or solely inflammatory, but 
apparently demanding loss of blood, e. g. in many neu- 
ralgic cases, and more remarkably in the beginning of 
continued fever, when large bloodletting is likely to be 
injurious, faintness is very easily produced in this way ; 
whereas, in strictly inflammatory cases, really requiring 
mucli loss of blood, a large quantity may usually be 
taken in the erect posture without faintness. It is not, 
however, to be inferred from this, that blood should al- 
ways be taken in the erect posture. The effect of the 
impression communicated to the heart through the ner- 
vous system is certainly not so permanent as that which 
is produced simply by the abstraction of the vital sti- 
mulus ; and some persons, even under strictly inflam- 
matory disease, become faint from the loss of blood in 



OF INFLAMMATION IN GENERAL. 



219 



the erect posture, before as mucli is taken as can pro- 
duce a permanent effect on their disease ; and it is 
therefore often advisable, when the existence of infla.m- 
mation of healthy character is early and clearly ascer- 
tained, to bleed with precaution, rather to retard or 
prevent, than encourage, the approach of fainting. 

2. The effect of bloodletting in causing derivation 
from parts actually inflamed to other parts of the body, 
has not been studied w^ith so much care as might have 
been expected from the pains bestowed on it by Haller. 
Whether this effect is, as he thought he had ascertained, 
inexplicable on merely mechanical principles, or whether, 
as Magendie and Poiseuille assert, it is merely the effect 
of the contractile power of the vessels, and the forced 
state of distension in which they exist during life, 
causing a flow to any point where an opening is made, 
it is quite certain that a movement in that direction is 
immediately perceived in all the small vessels which 
can be brought under the field of the microscope, on a 
puncture being made in any one of them ; and, in 
Haller's observations it distinctly appeared that this 
movement often inverted the natural course of the cir- 
culation, and often extended to portions of blood which 
were stagnating in vessels, and caused globules to sepa- 
rate and become distinct which had previously combined 
into irregular masses. This being so, it cannot be 
doubted that similar changes must be effected, in a 
greater or less degree, on the blood stagnating in in- 
flamed parts, when an exit is given to the blood from 
other parts of the circulating system, whether by gene- 
ral or local bloodletting. And it does not seem possi- 
ble to understand on what other principle than this, 
bloodletting can be useful, as it undoubtedly is in cer- 



220 OUTLINES OF PATHOLOGY AND PRACTICE. 



tain cases of inflammation, chiefly abdominal, where 
the pulse is smaller and even feebler than natural, but 
becomes fuller and stronger, — or in others (chiefly of 
the head, sometimes of the abdomen likewise) where it 
is slower than natural, small and sharp, and becomes 
more frequent and fuller, after the evacuation. 

It may be supposed that the chief effect of local 
bloodletting is in general of this last kind, and that the 
chief effect of general bloodletting is on the heart's 
action ; and it is certain that local bloodletting, by 
cupping or leeches, is often effectual in those inflamma- 
tions, generally of subacute character, which are unat- 
tended with disturbance of the general circulation ; and 
that it is in cases of well-marked local inflammation, 
attended and supported by general fever, that the power 
of general bloodletting is most distinctly seen. In such 
cases, however, the local remedy is very generally 
found^ after the force of the inflammatory fever has 
been somewhat broken, a most useful auxiliary to the 
other. 

No proposition in medical science is more certain, 
and certainly no one is more practically important, than 
that which regards the power of large and repeated 
bloodletting to arrest the progress of inflammation in 
its early stage, before any great amount of effusion has 
taken place, — and to cause many cases of it to termi- 
nate favourably by resolution, with such slight effusion 
only as is afterwards easily absorbed ; which would 
otherwise have gone on to extensive and probably fatal 
disorganization of the different kinds above mentioned. 
Indeed, it has been stated, and probably with truth, in 
relation to healthy inflammation occurring in a sound 
constitution, and unattended with mechanical injury to 



or INFLAMMATION IN GENERAL. 221 



the parts concerned, that " every constitution which is 
capable of having such inflammation excited in it, is 
capable also of bearing the evacuations, chiefly of blood, 
by which that inflammation may be subdued."* 

It may here be asked. How does it happen that some 
practitioners and teachers of medicine express them- 
selves so doubtfully as to its usefulness, even in diseases 
distinctly inflammatory, and place more confidence in 
remedies which are here stated as of very subordinate 
importance ? And again, if so effectual a remedy for 
inflammation exists, how does it happen that so great a 
portion of the mortality in all parts of the world de- 
pends on inflammatory diseases ? To the first objection, 
the proper answer is, that many medical men of high 
and deserved eminence have few opportunities of wit- 
nessing and estimating the eff*ects of the remedy in the 
early stage of violent inflammatory diseases. A physician 
whose practice lies chiefly among the higher ranks of 
society in a great town, — a consulting physician, who is 
called in by well-informed general practitioners, only in 
cases of unusual difficulty, and generally of some stand- 
ing, — an hospital physician, who sees the diseases of the 
poor only in that advanced stage when they are willing 
to leave home (particularly if there are well-conducted 
dispensaries in the neighbourhood) — has few opportuni- 
ties of judging of the power of bloodletting over the 
symptoms of inflammation, general and local, if em- 
ployed within forty-eight hours after a sudden and vio- 
lent attack in a healthy constitution. In civil hospitals, 
particularly, although inflammatory diseases are often 
seen, they are very frequently in those circumstances, 



Bateman. 



222 OUTLINES OF PATHOLOGY AND PRACTICE. 



either as to the stage of their progress, or as to compli- 
cation, in which, if recovery can take place, it must be 
chiefly the work of nature, and often incomplete. To 
the second objection, what has now been stated as to 
the period of inflammatory disease at which patients 
often come under treatment, is of itself almost a suffi- 
cient answer ; but a farther and still more satisfactory 
answer is to be found in what has been already stated 
as to the frequent deflection of inflammatory disease 
from the simple and healthy type, on which bloodletting 
exerts its most beneficial effect, and on its frequent 
complication with other diseased states, either imme- 
diately preceding it or accompanying it, and altering and 
augmenting the danger to be expected from it. 

The abatement of all the most urgent symptoms of 
inflammation produced by bloodletting is often very 
striking. The relief to dyspnoea and to palpitation, if 
either of these forms part of the symptoms of the dis- 
ease, is in general the most immediate, and is that 
which it is most important to observe at the very time 
of the operation ; because if not effected then, it is 
hardly to be expected afterwards. The relief to pain, 
especially in the head, is likewise often very rapid, but 
in other cases takes place more gradually, and is 
nevertheless equally complete within a few hours after 
the operation : many other uneasy feelings — heat, rest- 
lessness, thirst, anxiety, are often speedily relieved. 
But the advantage which is chiefly looked for, and re- 
garded as the most decisive and the best security for all 
others, is that which is effected on the state of the 
pulse ; and the change which is chiefly to be hoped for 
in it is, that it should become softer or more compressi- 
ble. If it at the same time becomes less frequent, the 



OF INFLAMMATION IN GENEEAL. 



223 



advantage is more decided ; but there are many cases, 
particularly in feeble subjects, where bloodletting is 
used with good effect, although the pulse, for a time, 
becomes more frequent, and at the same time softer, 
after the operation. 

One effect of bloodletting in inflammatory diseases 
is well ascertained, so far understood, and practically 
very important, viz. that by lessening that morbid im- 
petus of the blood by which, during the state of inflam- 
matory fever, the natural excretions are apparently im- 
peded, and at the same time, by promoting absorption 
into the blood, it favours the effect of all other evacu- 
ating remedies, intended to act on the excretions of in- 
dividual parts of the system. Hence it was judiciously 
laid down by Hoffmann as a general truism regarding 
this remedy, " Post venesectionem seepe excretiones 
salutares sanguinis, imo alvi, sudoris, urinee vacuationes, 
meliiis et liberiiis quam ante earn succedunt." 

In judging of the effects of bloodletting on inflamma- 
tion, it is important to observe, that the remedy may be 
highly beneficial, even in cases where the inflammation 
may extend, or the effusions consequent on it increase, 
after its use. It may often be observed in cases of 
pneumonia, that after full bleeding, the fever subsides, 
and the breathing is considerably relieved, but neverthe- 
less the indications by auscultation and percussion, of the 
extension of the effusion in the lungs and pleura continue 
for some days. But if the febrile symptoms do not re- 
turn, and the breathing continues easy, it may neverthe- 
less be confidently predicted, that, under proper manage- 
ment, and in a sound constitution, the case will terminate 
favourably, and the effusions gradually disappear, by 
absorption and by expectoration. In such cases it seems 



224 OUTLINES OF PATHOLOGY AND PRACTICE. 



quite reasonable to infer that the intensity of the inflam- 
mation and the quantity, probably also the density, of 
the effused fluids, are restrained by the bleeding, and 
the latter kept within the limits which the natural action 
of absorption can remove ; and from what we may often 
observe of the progress of erysipelas on the skin, in the 
more inflammatory cases of that disease, which are mo- 
derated and prevented from extending inwards to the 
cellular membrane, although not prevented from spread- 
ing along the surface, by bloodletting and analogous 
remedies, we may feel warranted in adopting this con- 
clusion. But this consideration seems to have been 
in some measure neglected by Laennec and others in 
France, whose attention has been fixed on the physical 
indications of effusion and disorganization of the lungs, 
and whose estimate of the value of bloodletting in in- 
flammations within the chest is much lower than that 
which most practitioners in this country have been led, 
from their observation of such diseases, to adopt. It is 
in a few cases only that bloodletting can be said (even 
on a general view of the symptoms) to cut short inflam- 
mation ; the more usual effect to be hoped for, is more 
correctly expressed by saying, that it disposes it to a fa- 
vourable termination. 

While such benefits are to be derived from the pyudent 
use of bloodletting in the strictly inflammatory diseases, 
and in their early stage, it is equally certain that in dis- 
eases not strictly of that type, and in the advanced stages 
even of the best marked inflammations, it may either 
aggravate and prolong the disease, or even rapidly de- 
termine its fatal event ; and nothing, therefore, can be 
more important than the diagnosis of the truly inflam- 
matory diseases, of the very various intensity with which 



3 



OF INFLAMMATION IN GENERAL. 



225 



they attack different persons, and of the degree of lesion 
of structure which may in any individual case have been 
already effected by them. 

The symptoms by which such distinctions are to be 
established belong, of course, to individual diseases to be 
afterwards noticed ; but there are two symptoms common 
to all inflammatory complaints, and often guiding in a 
great degree the use of bloodletting, on which a few ob- 
servations may be made ; these are the state of the 
pulse, and the state of the blood, in inflammatory dis- 
eases. 

In inflammatory diseases, the pulse may very often 
be distinctly observed not only to be more frequent, but 
also to be fuller, i, e. to cover a larger surface of the 
finger, and give the sensation of a greater expansion on 
each systole of the heart, — to be firmer or stronger, i. e, 
to be less compressible, — and to be sharper, L e. each 
of its pulsations to take place more suddenly than in 
health ; and when bloodletting takes a favourable effect 
in these diseases, or when they are spontaneously sub- 
siding, it may be observed to become not only less fre- 
quent, but also smaller, more comprerjsible, and softer. 
In general, it may be stated, that the more distinctly all 
these deviations from the natural state of the pulse can be 
observed in inflammatory diseases, we have the more 
confidence in bloodletting as the appropriate remedy ; 
and that hardly any case of inflammatory disease de- 
manding the remedy occurs, in which a deviation from 
the natural state in one or other of these particulars is 
not sufficiently obvious. But there are many cases of 
active inflammation admitting of the most essential bene- 
fit from bloodletting, in which one or more of the pecu- 
liarities here stated are absent. In one stage of inflam- 

P 



226 



OUTLINES OF PATHOLOGY AND PRACTICE. 



mation within the cranium we have very often the slow 
but firm and sharp pulse, observed also in certain cases 
of inflammation within the abdomen ; and in many cases 
of peritonitis and enteritis we have the frequent but 
small pulse, sometimes not distinctly harder or less com- 
pressible than in the natural state. It is also to be re- 
membered, that in youth the pulse is easily excited to a 
state differing from the natural in all the particulars 
above noticed, in the early part of febrile complaints 
which are not inflammatory ; and again, that in old age, 
when the arteries have lost somewhat of their elastic 
power, and transmit impressions from the heart, with less 
modification than in the natural state, particularly if the 
heart is at the same time affected with any degree of 
hypertrophy, the pulse is generally fuller, firmer, and 
stronger, or even sharper, than in the natural state. 

In regard to the huffy coat in the blood, there are oc- 
casional anomalies which are not yet understood ; but 
the general fact is, that, when inflammation is intense, 
there is not only a thick but a firm or contracted layer 
of coagulable lymph on the top of the crassamentum, 
implying that the particles of the fibrin have not only 
separated more completely from the colouring matter, 
and generally increased in number, in proportion to the 
other constituents, but aggregated together more closely, 
— or probably have continued longer under the influence 
of that vital property of attraction among themselves on 
which coagulation depends, than is usual. The forma- 
tion of a thick but loose and flocculent huffy coat is often 
observed in complex cases, as in typhoid fever, combined 
with local inflammation ; implying apparently that, al- 
though the separation of the fibrin from the colouring 
matter is complete, the vital property of attraction in its 



OF INFLAMMATION IN GENERAL. 



227 



own particles is soon extinguished, and this gives much 
less encouragement to the repetition of bloodletting. 

If, as is most probable, the blood acquires this 
change of property by passing through the vessels of 
the inflamed part, it is easy to understand that, for 
some time after even intense inflammation has set in, 
the huffy coat will be slight or even imperceptible ; and 
again, that when inflammation of some standing is de- 
clining, or still more, when it has passed into the stage 
of suppuration or ulceration, the huffy coat will still be 
found in perfection ; and therefore, that its absence or 
slight degree in the early stage of inflammation is no 
reasonable objection to bloodletting ; and that its pre- 
sence in the advanced stage (especially if suppuration is 
going on) is no indication for the remedy ; which are 
accordingly approved practical observations. 

The quantity of blood which should be taken in a case 
of well-marked inflammation, seen in its early stage, 
should never be prescribed beforehand, the only sure 
rule being to continue the loss of blood until either the 
pulse is affected, or giddiness and faintness are felt, or 
the local symptoms are decidedly relieved. Dr Cullen's 
statement, that for an adidt, previously in ordinary 
health, any thing below 12 oz. is to be regarded as a 
small bleeding, and any thing above 16 as a large one, 
may be held to be a fair average. From strong full- 
blooded men, distinctly affected with inflammation, from 
25 to 35 oz. may often be taken with signally good ef- 
fect. A single bleeding, even although carried to syn- 
cope, is seldom sufficient to control a well-marked inter- 
nal inflammation ; and Sydenham's estimate of 45 oz. as 
the average quantity requisite to meet the danger of a 
decided pleurisy, is not excessive. Dr Clark's statement 



228 OUTLINES OF PATHOLOGY AND FRACTICE. 



as to young children, that 3 oz. are a full bleeding from 
a child of one year, but that 2^ or 2 more may be taken 
at that age within a day or two, and even repeated in ob- 
stinate cases, may likewise be quoted as a judicious one. 
Three leeches, bleeding well, are a full bleeding for a 
child of one year, at least of the average strength of those 
brought up in great towns ; and if one is added for each 
year of the child's age up to five, a fair number for a- 
single evacuation may be obtained. Beyond this age, in 
strictly inflammatory cases, bleeding at the arm is cei*- 
tainly to be prefeiTed, 

There are a certain number of cases in which the 
symptoms of inflammation in its early stage, both local 
and general, either continue more obstinately, or occur 
more frequently, than usual, and in these it is of much 
importance to be aware how far the remedy may some- 
times be carried with good effect. There are various 
cases on record of pneumonia beginning with unusual 
intensity, in which 70 or 80 oz. within 12 hours, or 100 
within 24, even in a few instances within 12, have been 
taken with success, and in some of these farther blood- 
letting was necessary before the disease finally subsid- 
ed. On occasion of repeated occurrence of the disease, 
nearly 400 oz. have been taken from a patient within 
three months, and in the end he recovered perfectly. Mr 
Cline had a case of concussion of the brain in St Tho- 
mas's Hospital, in which 320 oz. were taken within three 
weeks, with success. 

It would be absurd to quote such cases as models for 
general imitation ; a great majority of patients, in the 
most decidedly inflammatory diseases, would certainly 
^sink under a much less active treatment, or pass into a 
state obviously forbidding the use of the lancet j but 



OF INFLAMMATION IN GENERAL. 



220 



vfhen we meet with cases where the early symptoms of 
inflammation resist obstinately, or recur frequently, it is 
of the utmost importance to know how far the ordinary 
remedies may be carried, under prudent management 5 
with success. 

The question of the comparative usefulness of general 
and local bloodletting in internal inflammations is not 
easily decided, but fortunately, in each individual case 
of severity, it is quite possible to try both, and be guided 
by the effect observed. No doubt can be entertained as 
to the importance of local bleedings succeeding venesec- 
tion, in all inflammatory diseases where the symptoms 
do not speedily yield to the lancet ; but in a case of de- 
cided idiopathic internal inflammation, attended with 
general fever, it may be confidently stated that early, 
and if the symptoms continue, repeated, bleeding at the 
arm should certainly never be omitted ; excepting only 
in the case of inflammation of the heart, supervening on 
rheumatism ; in which case repeated local bleedings, 
chiefly by cupping, are attended with more satisfactory 
results than bleeding at the arm. And in the case of 
the pericarditis in particular, it is easy to understand that 
full general bleeding will be attended with a danger quite 
peculiar, from the pressure of the effused fluid on the 
surface of the heart being naturally most injurious when 
the blood distending its cavities is subjected to sudden 
and great diminution of quantity. 

The dangers to be apprehended from excessive or in- 
judicious bloodletting, especially from the frequent repe- 
tition of the remedy, form a subject of great practical 
importance, of which a general outline may be here 
mven. , 

The danger of immediate death from the heemorrhage^ 



230 OUTLINES OF PATHOLOGY AND PRACTICE. 



in tlie hands of an attentive practitioner, may be regard- 
ed as trifling, there being always some warning, from the 
first symptoms of syncope, with or without spasms, of 
the time when it is prudent to stop a single bloodletting ; 
and generally such indications of general debility and of 
enfeebled circulation, from the compressibility of the 
pulse, coolness of the skin, paleness of the lips, and de- 
ficiency of mucous secretions, particularly dryness of the 
tongue, as sufficiently inform us when the repetition of 
the remedy has become a matter of doubt at least, if not 
absolutely inadmissible. But it must be allowed that 
there are many cases in which the system is powerfully 
affected by loss of blood, in which the repetition of the 
remedy is dangerous, if not immediately, at least in its 
ultimate result in the disease ; and in which, neverthe- 
less, there is a fallacious degree of fulness and even 
strength of the pulse, and a combination of symptoms 
which to those unaccustomed to observe them might seem 
to denote determination to the head, perhaps inflamma- 
tion of the brain, and to demand farther loss of blood. 

Of the possibility of this fallacious fulness and even 
sharpness of the pulse (generally a somewhat tremulous 
and easily compressed, but nevertheless sharp pulse, 
according to the notion formerly explained as being an- 
nexed to this last term), some of the experiments of Dr 
Parry on animals killed by repeated bleedings, and in 
which the pulse was " full and bounding" almost to the 
moment of death, afford unequivocal proof. And many 
practical observations by Rush, Armstrong, Marshall 
Hall, Travers, and others, illustrate this " reaction after 
the loss of blood which may perhaps be most correctly 
described as a modification of the inflammatory fever, 
produced in a great measure by the loss of blood, and 



OF INFLAMMATION IN GENERAL. 



231 



persisting after the local inflammation has subsided, or 
passed into a state no longer demanding evacuation. 
This peculiar febrile state is marked by the frequent, 
full, vibrating, or sharp, but easily compressed pulse, 
with heat of skin, generally, however, not persistent if 
the bedclothes are removed from the part felt, — -generally 
with sense of palpitation and of throbbing in the head, 
and tinnitus aurium ; sometimes impatience of light and 
sound; — the symptoms aggravated, and vertigo produ- 
ced by the erect posture ; the face and lips pale, and all 
muscular motion difficult and generally tremulous. This 
state occurs chiefly in females of irritable constitution ; 
and is best relieved by alternation of laxatives and 
opiates, often with the cautious use of wine, ammonia, or 
other stimuli. Where it coexists, as occasionally hap- 
pens, with still urgent symptoms of local inflamma- 
tion, it presents a case of much difficulty, but in which, 
although blood may often still be taken locally, general 
bloodletting is certainly dangerous. 

The idea of subsequent injury to the constitution, from 
the use of bloodletting, in inflammatoiy diseases, and 
particularly the idea of dropsy being thus produced, may 
in general be regarded as quite visionary. In persons 
liable to nervous affections, particularly to the various 
forms of hysteria, it is certainly true that an aggrava- 
tion of that tendency is to be expected ; which, however, 
will in general be only temporary, if the inflammation 
has been efl'ectually subdued. One of the chief practical 
evils which is always to be apprehended from large and 
repeated bloodletting is, that it always increases the fa- 
cility with which the surface of the body may be chilled, 
and therefore the liability to relapse, or to the excite- 



232 OUTLINES OF PATHOLOGY AND PHACTICE, 



ment of fresh inflammatory disease, perhaps of worse 
character, on any subsequent exposure to cold. 

But the principal cautions which it is necessary to 
keep in mind, as to the use of bloodletting in inflamma- 
tory diseases, have reference, not simply to the subse- 
quent efi'ects of the evacuation on the system, but to the 
alteration to be expected from it on the progress of the 
existinof disease : and in this view we must always care- 
fully attend — 1. To the period of the disease at which we 
are to use the remedy ; 2. To the kind of the inflamma- 
tion ; and, 3. To the complication which may exist of 
inflammation with other diseases. 

1. When we say that the period of the disease, even 
in cases of healthy inflammation, often decidedly con- 
tra-indicates, and still oftener makes us doubtful as to 
the result of bloodletting, Ave do not mean merely the 
number of days from the first decided attack of the dis- 
ease (although that always demands attention) ; but we 
must attend particularly to the proofs of eff'usion or dis- 
organization consequent on the inflammation, having al- 
ready made such progress as to indicate that the altera- 
tion of structure already eff'ected, rather than the alte- 
ration of action which leads to it, demands our chief at- 
tention. And, in general, as already remarked, this 
may be apprehended when we see a manifest change in 
the constitutional or febrile sipnptonis, attended with con- 
tinuance or increase of the local symptoms. The time 
when this change of symptom takes place, is exceedingly 
various in all the inflammations, but it is to be looked for 
in all. If recovery is possible after this period, a long 
and slow process must be gone through before it can be 
perfected ; and this will require a certain strength of vital 



OF INFLAlVmATION IN GENERAL. 



233 



action, and may be frustrated by any means which further 
depress the vital powers nay, it may, in many instances, 
be obviously promoted by means which excite the system 
generally, and stimulate and strengthen the circulation. 

In many such cases, more definite information is at- 
tainable, particularly in the case of inflammation within 
the chest, whether affecting the bronchise, the substance 
of the lungs, the pleura, the pericardium, or inner mem- 
brane of the heart, — the indication given by examination 
of the chest and of the sputa, and by auscultation and 
percussion, prove the extent of effusion, and the degree 
in which the play of the lungs or heart is impeded by it ; 
and these taken along with the state of the pulse, heat 
of skin, and general strength, may often enable us to 
speak with much confidence as to the question, — always 
presenting itself in the advanced stage of these diseases, 
- — whether there is more danger from weakening the 
circulation by bloodletting, w^hen such impediments to 
the action of parts within the chest already exist, and 
can only be remedied by a slow and natural process of 
absorption, or from allowing such inflammation as still 
exists to go on, unchecked by farther loss of blood. 

2. That inflammation may exist of a nature not to be 
subdued, even to be aggravated, by bloodletting or other 
evacuations, is quite certain from such experiments as 
those of Magendie as to the eye, and of Gendrin as to 
the stomach ; in which the kind of inflammation of mu- 
cous membrane formerly mentioned w^as brought on by 
inanition, and could only be relieved by fuller nourish- 
ment, restoring the strength of the circulation, and pro- 
bably restoring to the mucous membrane its natural pro- 
tecting mucus ; and that the kind of inflammation which 
is recognised in a patient affords very often a reasonable 



234 OUTLINES OF PATHOLOGY AND PRACTICE. 



ground of objection to full bloodletting is sufficiently 
obvious when we attend to the known history of scrofu- 
lous, rheumatic, and gouty inflammation. In the first 
of these, it is true, that, on occasion of a recent inflam- 
matory attack, when the symptoms approach most nearly 
to those of healthy inflammation, we have every reason 
to believe that bloodletting is often of the most essential 
importance, preventing aggravation of disease already 
existing, or arresting disease which would otherwise be 
established. But scrofulous inflammation is less under 
the influence of bloodletting than healthy inflammation ; 
and scrofulous diseases occur chiefly in weakly persons, 
in those whose mode of , life in early youth has been de- 
bilitating, and in those recently weakened by any consi- 
derable evacuations. Therefore, by full and repeated 
bloodletting in scrofulous cases, while we make little im- 
pression on the inflammation that exists, we incur a 
great risk of so far lowering the constitution as to make 
it more liable than previously to fresh attacks of inflam- 
mation, or to other scrofulous diseases, perhaps not in- 
flammatory in their origin. 

Again, the recorded experience of all ages informs us 
(whatever we may conjecture as to the explanation of 
the fact) that the inflammation both of rheumatism and 
of gout is very liable to metastasis, and that, although 
it may often be moderated (particularly the acute rheu- 
matism in a healthy constitution) with very good effect 
by evacuations, yet it is by no means desirable that 
it should suddenly recede from the extremities ; because 
if it does, inflammation in a more vital organ, or in the 
case of gout, a kind of internal neuralgia, even more im- 
mediately dangerous, is very likely to follow. 

In the case of erysipelas, to a certain degree, and in 



OF INFLAMMATION IN GENERAL. 235 



that of all the specific inflammations of the skin already- 
noticed, in a much greater degree, the nature of the in- 
flammation may also be urged as a reason against full 
bloodletting, and in favour of the strictly " expectant 
practice but these are cases, either of inflammation 
without fever, or of inflammation complicated with an- 
other and generally more formidable disease, falling 
therefore under the next head. 

3. The complications of inflammation which often 
contra-indicate bloodletting, and always impose the ne- 
cessity of caution in regard to it, are in a general view 
of two kinds ; that with other febrile and particularly 
contagious diseases, and that with chronic and particu- 
larly organic diseases. 

In regard to the complication of inflammation with 
idiopathic fever, or with the contagious exanthemata 
(in which we include erysipelas), the general principle 
is, that such inflammation, whether of the kind that is 
essential to and characteristic of the disease, or of that 
which is only an accidental concomitant, is never the 
sole, and seldom the chief, cause of danger. The body 
is under the influence of a poison, generally absorbed 
from without, which gives a peculiar character to the 
inflammation, and likewise excites a peculiar form of 
fever, often very dangerous when the inflammation, ex- 
ternal or internal, is trifling. In the course of the 
disease, the poison, after being enormously multiplied, 
by some mysterious process, is expelled from the body. 
Whether the inflammation is part of the process by 
which this expulsion is effected, is indeed doubtful, but 
it is certain, that, in most of these diseases, the inflam- 
mation, at least that which is characteristic and pecu- 



i 



236 oriLiNES OF pathology and practice. 



liar to the disease, cannot be prevented from running a 
certain course without imminent danofer to life. 

The danger in the course of these diseases depends 
often mainly on the depressing eflPect of the morbific 
poison, gradually influencing the system at large and 
especially the fundamental function of circulation, and 
producing typhoid fever ; but it often depends on the 
combination of the depressing influence with inflamma- 
tion, internal or external ; and sometimes it depends so 
much on the intensity of the inflammation, and so little 
on any general depression of the powers of life, that 
the disease demands and bears evacuations nearly as in 
idiopathic inflammation. In judging of the degree in 
which the danger of individual cases depends on the 
one or other cause, there is of course much room for the 
exercise of judgment and discretion. Two general ob- 
servations may be made, which are of great practical im- 
portance : 1. That in all such complex cases, where con- 
tra-indi cations exist, if bloodletting is to be practised 
(and in the accidentally concurrent inflammations in 
many cases of such diseases it is highly beneficial), it 
should be practised as early as possible, in order that it 
may be as small as possible ; all experience informing us 
that a very moderate loss of blood in the early stage of 
inflammation will often produce much more effect on the 
extension and course of the disease than a much larger 
quantity at an advanced period. 2. That in the course 
of. such diseases we are not to expect the symptoms of 
any concomitant local inflammation to abate entirely, 
while the fever lasts, and must be content with mitiga- 
tion of their urgency. 

There is another element which must always be 



OP IXFLAMMATIOX IN GENERAL. 



237 



taken into consideration here, whicli is quite peculiar to 
sucli diseases, viz. tlie nature of tlie prevailing epide- 
mic ; for it is tlie general result of tlie observation of 
medical men in different ages, that, in different epide- 
mics, the tvpe of the same disease so far varies, that the 
local inflammation may be more frequent and danger- 
ous in the generality of cases occurring in one, and the 
general typhoid state in those occurring in another. 
Thus it is the general result of the experience of most 
practitioners who have seen much of the epidemic fevers 
prevalent in Scotland from 1816 till 1820, and again of 
those prevalent since 1826, — that bloodletting was both 
more demanded, from the firmness of the pulse and the 
urgency of local symptoms, and better borne, at the for- 
mer time ; and that the danger much less frequentlv 
depended on mere depression of the circulation ; and 
again, that, in the later epidemics, this last part of the 
symptoms has been much more generally urgent, the 
use of stimulants has often appeared much more import- 
ant and beneficial ; and that full bloodletting, even 
early in the disease, has often appeared to exert a very 
injurious influence over its subsequent progress. Simi- 
lar observations have been made on different epidemic 
visitations of all the febrile and contagious diseases. 

Of the caution in regard to bloodletting which is im- 
posed by the presence of chronic, and especially of 
organic disease, we may merely enumerate the cases of 
inflammation of the lungs or bronchia^ combined with 
disease of the heart, or with previous long-continued 
asthma and its usual attendant, emphysema of the 
lungs : and again, of inflammation within the abdomen, 
whether of the serous or mucous membrane there, com- 
bined with organic disease of the liver. Such cases are 

9 



238 OUTLINES OF PATHOLOGY AND PEACTICE. 



very common, and are very often farther complicated 
with dropsical effusion, partial or general. It is very 
important to be aware, and has been ascertained of late 
years more distinctly than formerly, that none of these 
complications ought to prohibit bloodletting when the 
inflammatory symptoms are recent, and the circulation 
tolerably firm and vigorous. But it is obvious that, in 
such cases, the system is permanently under the influ- 
ence of a cause which prevents it from recovering its 
natural strength after any gTeat evacuation, as it other- 
wise would do. And in several such cases, a more 
special cause of danger from much loss of blood may be 
pointed out, particularly in the cases of advanced pec- 
toral disease, in which free expectoration is both difficult 
and necessary for recovery ; and the cases of dropsical 
effusion, where a mechanical impediment exists either 
to free circulation or to the expansion of the lungs. It 
is obvious, from these considerations, that the time 
during which bloodletting can be beneficially employed 
in such diseases, must be very circumscribed ; although 
it must be admitted, on the other hand, that some cases 
of all these occur, in which the strength of the circula- 
tion is such as to make it safe and beneficial at a much 
more advanced period than in others. The case of 
mechanical obstruction to the flow through the heart, 
from disease of its valves or of the aorta, unconnected 
with organic alteration either of the lungs or liver, is 
that in which the repeated loss of blood may generally 
be best borne. 

Much has been said, in some systematic works, of 
age, sex, temperament, habit of body, habits of life, 
climate and season, as influencing the use of this reme- 
dy ; but the fact is, that there is no age, no sex, tem- 



OF INFLAMMATION IN GENERAL. 



239 



perament or habit of body ; no description of human 
beings, and no climate or season, in which bloodletting 
may not, on certain occasions, be performed with ad- 
vantage, — nay, there is none in which its neglect may 
not be fatal. All that can be said on those heads is 
chiefly important as pointing out the circumstances in 
which the indications or contra-indications already 
stated are chiefly to be expected, but can hardly be 
said to establish any new rules. 

In early life there is certainly ground for caution — 
first, because much febrile action may be excited even 
by slight inflammation, and secondly, because young 
children are easily depressed by repeated evacuations, 
perhaps especially of blood ; and are apt to fall when so 
afl*ected into the state described of late years, under the 
name of hydrencephaloid disease ; in which stupor, 
with coldness of surface, feeble pulse, and vomiting, are 
the chief symptoms, and in which stimulants are often 
signally useful. 

In very advanced life there is ground for caution, 
partly on account of the complication with alteration 
of structure, which may very often be suspected, even 
when it is not certainly known, and partly because the 
powers by which the capillary circulation is maintained, 
and the vital actions by which the blood is applied to its 
various useful purposes in the economy, lose much of 
their efficacy at this time, and the system, therefore, 
has usually not the same powers as previously of re- 
covering from any debilitating cause. 

In regard to sex, it is important to observe that in 
women, slight inflammatory attacks, with severe pain, 
and often with much fever, or severe neuralgic attacks, 
with threatening of inflammation in the spinal cord, in 



240 OUTLINES OF PATHOLOGY AND PRACTICE. 



the sides of tlie chest, and in the viscera of the abdo- 
men and pelvis, often occur, and mislead young practi- 
tioners into the belief that violent and internal inflam- 
mation exists when it does not. But it is not less true 
that the most intense inflammations occur in them pro- 
bably more frequently than in men ; and it were a fatal 
error to suppose that the presence of nervous or hyste- 
rical symptoms implies the absence of serious inflamma- 
tion. 

In regard to climate, the most truly important ob- 
servation seems to be, that in hot climates the progress 
of febrile and inflammatory diseases — at least on Euro- 
peans — is accelerated, and the time when bloodletting 
can be useful of course proportionally circumscribed. 

The sanguine temperament is that in which the great- 
est intensity both of pain and of fever may be expected 
to attend a given amount of inflammation ; and there- 
fore, when we have urgent general symptoms attending 
local inflammation in persons of a temperament much 
removed from the sanguine (in the phlegmatic or me- 
lancholic), we have the more reason to suppose that the 
inflammation is intense ; and if it be in the early stage, 
that full bloodletting is demanded. But it is of much 
more importance to observe the degree of strength of 
habit, than the temperament, in judging of the extent 
to which bloodletting may be carried. The inhabitants 
of large towns, partly on account of their more sedentary 
life, partly of the impure air which they habitually 
breathe, partly of their less regular mode of life, their 
more frequent mental anxieties and irritation, are of 
feebler habits ; and all the cautions as to repeated loss 
of blood apply to them more than to country people. 
There are indeed many of them, in comfortable circum- 



OF INFLAMMATION IN GENEEAL. 



241 



stances and of regular habits, who bear bleeding perfectly 
well ; but there is a class, well described by Dr Arm- 
strong, always numerous in large towns, whose subsist- 
ence is precarious, whose habits are irregTilar, and often 
dissipated, who are exceedingly prone to inflammation, 
but have it in a form modified by these circumstances, and 
especially by the habitual use of strong liquors. In many 
of these full bloodletting will produce fits of delirium 
tremens ; in others it may affect variously the nervous 
system ; and in all it must be expected to depress the 
circulation more permanently than in better constitu- 
tions. In all such cases, our main resource is the early 
detection of inflammatory disease, and the early, and 
because early, moderate, and yet effectual, use of blood- 
letting. 

We may comprise in a few words all that need be 
stated in general terms as to the other classes of reme- 
dies to be employed in such cases. 

1. When inflammation is near the surface of the body, 
we have a powerful means of repressing it in the appli- 
cation of Cold, which, by causing constriction of the di- 
lating vessels, prevents those congestions and stagnations 
of blood which seem to be essential to the inflammatory 
effusions. The application of cold water to a burn, 
which has caused inflammation, and commencing vesi- 
cation, — or to a bruise or sprain, affords unequivocal 
evidence of the power of this agent ; but, in order that 
it may be effectual, it must be applied either uniformly, 
or very assiduously for many hours together, otherwise 
the inflammation will start again, as if with renewed 
vigour, on each cessation of the application, as long as 
the general strength of the circulation continues, and 
the remedy will, on the Avhole, rather retard than hasten 
4 Q 



212 OUTLlxNES OF PATHOLOGY AND PRACTICE. 



its decline ; and it is difficult to do this without some 
risk of the injurious effects of cold. In those varie- 
ties of inflammation which have the natural tendency 
to shift their place, and especially to affect internal 
parts, it need hardly be said that this mode of re- 
pressing external inflammation is inadmissible. Al- 
though cold applications may be used in these when the 
circulation is firm and vigorous, it must be only with the 
intention of relieving the feelings of the patient, — not to 
such an extent as to affect materially the progress of the 
inflammation. 

Of internal inflammations, that within the head is 
that in which the assiduous application of external cold 
has been most esteemed, — both in the way of fre- 
quent sponging or aspersion, and in that of occasional 
stronger affusions ; but it is in cases of subacute inflam- 
mation, or determination approaching to the inflam- 
matory state (as in the course of idiopathic fever), that 
it is most useful. Certainly, in cases of idiopathic in- 
flammation, or of threatening hydrocephalus, it cannot 
be urged as superseding the active depleting measures. 
In some cases of peritoneal inflammation, the assiduous 
external application of cold is grateful to the patient, 
and probably may assist in restoring the natural state of 
the bowels ; but the application must be strictly confined 
to the inflamed parts, and this is often difficult. This 
observation applies still more to the application of cold, 
practised occasionally on the Continent, hardly at all in 
this country, in cases of cynanche, especially of croup. 

2. Of the various sedative medicines which, at diffe- 
rent times, have been highly recommended as capable 
of controlling both the local and the general disorder in 
inflammatory diseases, we may assert in general, that no 



OF INFLAMMATION IN GENERAL. 



243 



one is generally thought in this country deserving of 
confidence which is not nauseating ; and that the anti- 
phlogistic effect, if not absolutely dependent on, seems 
very much connected with, the sensation of nausea, 
and accompanying depression of the hearths action. The 
effect of Digitalis in lowering the pulse is seldom to be 
obtained without its nauseating effect ; and this can 
hardly be produced within so short a time as the progress 
of an acute disease demands, without danger of fatal 
syncope. Whatever may be the specific power of Col- 
chicum over gouty inflammation, it is certainly not to be 
depended on as sensibly influencing simple, or even 
rheumatic inflammation, unless so used as to nauseate. 
Several high authorities on the Continent have expressed 
a confident opinion of the antiphlogistic virtue of Tar- 
trate of antimony, when given in large quantity, after 
tolerance of the medicine has been established, and when 
it produces no sensible effect^ being such as nearly to su- 
persede the necessity of bloodletting j but such trials as 
have been made in this country have not established this 
principle to the satisfaction of the profession. Indeed, 
the effect of from a quarter of a grain to half a grain of 
tartar emetic every two hours during the time of waking, 
in cases even of well-marked internal inflammation, is 
distinctly nauseating, when blood has been previously 
freely drawn ; and as the chief beneficial effects of the 
remedy, as auxiliary to bloodletting, have been observed 
in connection with the occasional fits of nausea, there 
has been no great anxiety to observe the effects of push- 
ing the medicine further. The antimonial solution thus 
used, or some other nauseating medicine, is probably the 
most powerful auxiliary to bloodletting in the early stages 
of inflammations within the chest, especially in that of the 



24:4: OUTLINES OF PATHOLOGY AND PRACTICE. 



substance of the lungs ; and it is a very powerful remedy, 
also, in those cases of affection of the brain, occurrinof in 
fever, in which there is high delirium and an approach 
to inflammation, though without nausea ; hut in the 
early stage of almost all cases of idiopathic inflammation 
in the head, as well as in the abdomen, there is so much 
nausea and vomiting as obviously to contra-indicate the 
remedy ; and, in all cases, caution is requisite in its use. 
on account of its sometimes violent effects on the heart's 
action, and on the stomach and intestines. 

3, The most frequently employed of all the auxiliaries 
to bloodletting are the various methods of derivatmu of 
which purging, carried to the extent of considerable 
watery evacuation, is by far the most generally import- 
ant. This is the main auxiliary to which we must trust 
in cases of inflammation within the head : and its use 
there is the more important, that ^^as Dr Abercrombie 
has stated) purgatives may be used fully, and sometimes 
most efiiciently. after the symptoms of effusion conse- 
quent on inflammation in the brain, have come on, and 
when farther loss of blood is useless or even injurious. 
In inflanmiation within the chest, although occasional 
laxatives are proper in the view of lessening the general 
febrile state, they are of less essential importance : and 
when there is much expectoration in the later stages, it 
is generally, and probably justly, thought, that much 
purging may be injurious. 

In inflammation of the intestines, both of the serous 
and mucous membranes, they were certainly much too 
generally employed in this country within these few- 
years: but it is now more generally understood that, 
in reducing inflammation there, they are not only of 
little efficacy, but always of doubtful, and sometimes 



OF INFLAIVIMATION IN GENERAL. 



245 



of injurious, effect, — that procuring a regular action of 
the bowels is a secondary object, not to be directly urged 
until the inflammation has subsided j and that, even for 
attaining this object, the mildest laxatives and enemata, 
generally alternated with opiates, are the most appro- 
priate means. 

Vomiting appears to be an important auxiliary to 
bloodletting chiefly in cases of inflammation of the larynx, 
trachea, and bronchise, especially in children, where it 
seems to have a special efl'ect, partly as an expectorant, 
and partly as an anti-spasmodic. 

The efl'ect of diaphoretics and sudorifics in inflamma- 
tory complaints is not easily referred to any fixed prin- 
ciple. In many of them, especially in thoracic inflam- 
mation, there is often full sweating without the least 
alleviation ; and it is certainly highly inexpedient, in the 
height of any inflammatory disease, to urge the use of 
such sudorifics as produce a manifest previous excite- 
ment of the circulation. In the inflammatory diseases 
of children, in particular, the premature use of the 
warm bath is certainly often injurious. Yet there are 
cases of strictly inflammatory diseases, in their early 
stages, particularly of bronchitis, of dysentery, and of 
rheumatism, in which sweating, generally succeeding to 
moderate loss of blood, sustained sometimes for two or 
three days, and with proper precautions against subse- 
quent exposure to cold, is signally beneficial ; and it 
is perhaps more generally useful when the violence of 
internal inflammation has subsided. 

The use of blisters and other counter-irritants is con- 
fined chiefly to peculiar circumstances of inflammatory 
complaints, — to the later stages of acute inflammation, 
when the excitement of the system has been so far re- 



246 OUTLINES OF PATHOLOGY AND PRACTICE. 



duced by bloodletting ; to the cases of more chronic or 
subacute inflammation ; e. g. to many cases of bronchitis 
and rheumatism especially of the synovial membranes ; 
and again to the inflammation, and especially the slow 
scrofulous inflammation, of those textures where the 
whole progress of inflammation is slow ; bones, car- 
tilages, and hgaments. In many of these last cases, 
the issue or seton is the most suitable and eff'ectual 
form of counter-irritation. In all forms, the degree of 
excitement they occasion in the first instance, is a serious 
objection, particularly in children, in whom also, the 
ulceration and sloughing, consequent on blisters, if ap- 
plied only for a few hours, in a feeble habit or in a de- 
pressing disease, is often not only troublesome but dan- 
gerous. 

4. Many practitioners in this country, since the time 
of Dr Hamilton of Lynn Regis, have been convinced 
that there is a peculiar or specific virtue in Mercury, 
afi^ecting the mouth, and especially in the combination 
of calomel and opium, in arresting inflammation, and 
controlling the deposition of lymph from it ; and that a 
power of this kind is exerted over the inflammation of 
the iris, and the effusion of lymph upon it, in many cases 
of that disease, no one can doubt. But that a similar 
power is exerted, in a degree adequate to the object re- 
quired, in any inflammation of internal parts, is much 
more doubtful. That calomel and opium, used in mo- 
deration, is a useful medicine in many internal inflam- 
mations, is granted by all, because the soothing eflects of 
the opium are often desirable, and the calomel is one of 
the simplest and most efl'ectual means by which some of 
the injurious efiects of opium may be corrected ; but the 
main question, as regards any specific virtue of mercury, 



OF INFLAMMATION IN GENERAL. 



247 



is this — Do the symptoms of inflammatory diseases sub- 
side more rapidly, and more certainly, when the mercury 
has affected the mouth, than without that occurrence? 
and on this point observations are somewhat at variance. 
It may, however, certainly be stated in general terms, 
that the cases in which that combination has seemed 
most useful, have been most frequently those in which, 
the symptoms having subsided, it was withdrawn without 
the mouth being touched, and therefore without any 
proof being given of its specific virtue. 

5. That Opium is an important and valuable auxiliary 
to bloodletting in abdominal inflammations, is a principle 
which seems firmly established by the practice of various 
physicians in this country. It appears that its value 
(except as a palliative to uneasy feelings) is nearly con- 
fined to the inflammations of the intestines, enteritis, 
and dysentery, and that it is important in them, not to 
diminish the quantity of blood which should be drawn 
to subdue the inflammation, but to relieve those very 
oppressive sensations which seem to be the connecting 
link between the inflammation in the intestines and the 
actions of the heart, and by which these actions are so 
often rapidly and irretrievably depressed. Under the 
full use of opium, after bleeding in these diseases, these 
feelings are often relieved, vomiting allayed, sleep 
procured (whether with or without sweating does not 
appear to be material), and the pulse is found to rise in 
strength ; and if, as very generally happ^is in well- 
marked cases, the inflammatory symptoms recur, blood- 
letting may be repeated again and again, without sympv 
toms of sinking. The disease is placed, as to its possible 
duration, and the effects of repeated bloodletting, more 
on a footing with inflammations of other parts, than it 



248 OUTLINES OF PATHOLOGY AND PRACTICE. 



is when tliis auxiliary is omitted. Under this treatment, 
it may be stated with confidence, that the success of 
treatment in these inflammations, when attended by the 
peculiar depression of the circulation, and when the in- 
flammation is of the healthy character, as distinguished 
from the erythematic and often epidemic peritonitis, is 
very considerably greater than when opium is withheld. 

6. There is yet another class of remedies of great and 
certain efl&cacy in certain circumstances of inflammatory 
diseases, although of course requiring much discrimina- 
tion in their use, yiz. the Stimulants. These are admis- 
sible, of course, only in the later stages, but sometimes 
sooner than the indications for local bloodletting, or the 
time of its useful employment, haye ceased. They may 
be demanded by two distinct considerations : 1. By there 
being such indications of debility or deficient action in 
the pulse, skhi, tongue, and yoluntary muscles, as are in 
themselves very dangerous, and may render a local dis- 
ease fatal, which might otherwise either have abated or 
passed into a chronic and comparatively inert state. 
2. By certain consequences having already resulted from 
the inflammation, known to be irremediable for the time, 
but admitting of a subsequent slow process of cure by 
the provisions of nature, provided a certain amount of 
the vis vitse in the system in general can be maintained 
for the requisite time. 

Dr Abercrombie has shewn that the deadly paleness 
and coldness, with cessation of the pain, and sinking of 
the pulse, so often seen and so generally fatal in the last 
stage of enteritis, may in a few cases go ofi" under the 
cautious but continued use of stimuli. There is no case 
in which more decided beneficial effects can be some- 
times observed from stimuli, than the advanced stage 



OF INFLxiMMATION IN GENERAL. 249 



of bronchitis, wlien the breathing is very short and hur- 
ried, the mucous and subcrepitous rale general on both 
sides of the chest, the skin cool, and the pulse sinking. 
In some such cases, the breathing is relieved by full ex- 
pectoration, obviously promoted by the stimuli ; but in 
others it gradually improves as the pulse rises in strength, 
although the expectoration is scanty. These are even 
cases of the true peripneumony (no doubt partial) marked 
by the peculiar sputa, with the absence of respiration in 
the affected part of the chest, — neglected until their ad- 
vanced stage, — attended with a similar depressed state 
of the circulation, and recovering (although with some 
permanent injury to the lungs) under the use of stimu- 
lants exclusively, taken in such quantity, and followed 
by so rapid abatement of the most distressing symptoms, 
that they could not be supposed to have exerted no in- 
fluence on the disease. 

Again, although there be no such immediately alarm- 
ing symptoms, if bronchitis has produced general effusion 
into the bronchiae (as in many advanced cases of asthma 
and of hooping-cough) ; if a portion of lung has been 
consolidated ; if an extensive and probably partly puri- 
form effusion from decided inflammation has taken place 
in the cavity of one side of the chest or abdomen ; if an 
abscess has formed in the liver ; if a portion of the mu- 
cous membrane of the intestines has been thickened by 
effused lymph, and then passed into ulceration ; if a bone 
has become carious, a cartilage has ulcerated, or even a 
capsular ligament of a joint been much thickened by 
inflammatory deposits ; if the cornea has been affected, 
first with pustules and then with ulcers, from the stru- 
mous form of ophthalmia, — whatever influence local re- 
medies may or may not have on such lesions, it is certain 



250 OUTLINES OF PATHOLOGY AND PRACTICE. 

that a long process of absorption, of ulceration, of heal- 
ing by granulations, &c. in these different cases, must 
be gone through ; and that a certain degree of strength 
of habit is necessary, that these processes may go on 
favourably. We know, from experiments on aiiimals, 
that inflammation, with all such consequences (e. g. in 
the eye), may be produced, if not merely by inanition, 
at least by causes acting on a very exhausted system, 
and producing this effect by reason of the exhaustion ; 
and that all may be removed merely by giving sufficient 
nourishment ; and therefore we can easily understand, 
what experience abundantly demonstrates, that not only 
the antiphlogistic remedies after a time must be discon- 
tinued, but the antiphlogistic regimen relaxed, even 
sometimes at the risk of temporary aggravation of part 
of the disease, in such cases ; and that the best effects 
should result from the gradual introduction of a tonic 
regimen, from country air, exercise, moderate mental 
excitement, and a gradually improved diet. Such cases 
illustrate strongly the mischief which may be done by 
practising for the names of diseases ; and forcibly remind 
us of the judicious aphorism of Boerhaave, " Nullum re- 
medium in morbis cognovi, quin solo teinpestivo usu tale 
fiat," 



( 251 ) 



CHAPTER II. 

OF INFLAMMATIONS OF THE AIR PASSAGES AND LUNGS. 

We begin with the Inflammations in the trunk of the 
body, because the Pathology of these is important, as 
illustrating that of other parts, particularly the head. 

Excluding the case of the Cynanche Maligna, which 
belongs clearly to the second great division of Febrile 
Diseases, we have to consider two frequent and import- 
ant diseases depending on inflammation of the throat, 
the Cynanche Tonsillaris and Trachealis. 

Sect. I. — Of the Cynanche Tonsillaris. 

This disease is accurately described by Dr Cullen, as 
" membranam faucium mucosam, et prascipuse tonsillas, 
tumore et rubore afficiens, cum febre synocha.^'' The 
pain on deglutition is often intense, and shooting to the 
ear, and the deglutition difficult or imperfect ; the voice 
is peculiarly altered by the swelling of the tonsils ; the 
inflammation is attended with exudation of lymph, 
generally at the mouths of the orifices of the mucous 
glands, sometimes extending over the uvula, and part 
of the velum pendulum ; but when the inflammation is 
strictly of the healthy character, this exudation very 
seldom goes farther, and the inflammation, beginning at 



252 OUTLINES OF PATHOLOGY AND PRACTICE. 



the tonsils, seldom passes into tlie larynx, even although 
the breathing becomes laboured and noisy from the 
swelling of the tonsils ; there is external tenderness, but 
little or no swelling of the lymphatic glands beneath 
the angle of the jaw. By this mark, by the absence 
of any peculiar swelling or redness of the papillae of 
the tongue, and by the absence, both of eruption on 
the skin, and of any unusual sickness or depression in 
the beginning, or typhoid symptoms in the progress of 
the concomitant fever, this disease is usually distin- 
guished without difficulty from the Cynanche Maligna ; 
and from incipient continued fever, or other strictly fe- 
brile diseases, which are frequently attended with in- 
flammation of the fauces, it is distinguished in its early 
stage, chiefly by the swelling of the tonsils, and conse- 
quent difficulty of swallowing and aff'ection of the voice, 
being much greater. 

The fever attending this disease, is often much more 
intense than" could be expected from the size of the 
organ inflamed, and may sometimes be distinctly ob- 
served to precede the local pain. 

There are cases, simply inflammatory, in which the 
inflammation is more intense, and apparently deeper 
seated, afl'ecting more of the sub-mucous cellular tissue 
than usual, and especially causing much swelling and 
tenderness of the back part of the tongue, attended 
with almost complete loss of the power of swallowing, 
and with salivation, and demanding more energetic 
treatment than is usually thought necessary.* But 
more frequently such urgent symptoms result from in- 
flammation of a specific character, — sometimes from the 

* See Craigie's Practice of Physic, vol, ii. p. 401. 



INFLAIVBIATIONS OF THE AIE PASSAGES, &C. 253 



diffuse inflammation of Erysipelas, — more frequently 
from that attendino- one form of the Cynanche Malio^^a. 

This disease generally originates pretty distinctly in 
exposure to cold or wet, but is excited in young and irri- 
table constitutions much more readily than in others, 
and in some individuals and families with remarkable 
facility. 

In healthy persons, and under a moderately antiphlo- 
gistic regimen, this inflammation usually subsides in a 
very few days, — being protracted, however, some days 
longer in a small proportion, when it goes on to sup- 
puration, and the discharge of purulent matter, always 
remarkably fetid. Even such a case is hardly ever 
dangerous, the opening of the abscess when the suppu- 
ration is complete gives immediate relief ; but there are 
a few cases of inflammation of this healthy character, 
going to suppuration, but seated lower down the pharynx 
(C. pharyngeea) where the swelling and suppuration are 
so situated, and become so great, as to press on the 
glottis, and produce stridulous respiration, and may 
cause death by Asphyxia, as in croup.* 

i^lthough the disease in its simple form is generally 
at an end in a few days, yet even if originating in the 
usual way, it is apt to recur repeatedly, or become 
chronic and very troublesome or even dangerous, in 
several cases, which demand attention. 

1. In some persons of somewhat feeble and languid 
habit, where the inflammation continues long, generally 
assuming a purplish colour, with little swelling, and 
little febrile reaction, — constituting what, in vulgar lan- 
guage, is called a relaxed sore throat. 

* See, e. g., Abercrombie in Edinburgh Medical and Surgical 
Journal, 1819, 



254 OUTLINES OF PATHOLOGY AND PRACTICE. 



2. In others, often stronger in appearance, but gene- 
rally of scrofulous habit, where the tonsils remain long 
enlarged and hard, or even pass (particularly under re- 
peated applications of cold and wet, or other irritations) 
into chronic ulceration. 

3. In those who are infected with syphilis. 

4. In those whose constitutions have been much af- 
fected by mercury. 

The concurrence, either of syphilitic or mercurial 
affection, with the "scrofulous habit, is the case in which 
inflammation of the throat, even if slight in the com- 
mencement, is most apt to pass into obstinate ulcera- 
tion, extending to the velum and uvula, to the back of 
the pharynx, or to the cartilages of the larynx. 

It is also to be observed, that an epidemic sore throat 
has occasionally prevailed in difterent situations, not 
corresponding to the character of the Cynanche Maligna, 
or Scarlatina, but much more dangerous than the com- 
mon form of Cynanche Tonsillaris, for two reasons ; 
firsts because attended with more depression of strength, 
or typhoid fever ; and, secondly^ because tending to the 
effusion of a flocculent membrane on the tonsils and 
pharynx, sometimes extending down the oesophagus, 
and often down the larynx, where it produces the symp- 
toms of croup. In this case the inflammation is ob- 
viously of a specific, and it may be said of an Erythe- 
matic character, and the causes of its occurrence and ex- 
tension are as obscure as of the Erysipelas. To this form 
of the disease the term Diphtherite has been applied. 

In all cases of the Cynanche Tonsillaris, and espe- 
cially in cases where the chronic sequelae, above noticed, 
are to be dreaded, the antiphlogistic regimen is to be 
enjoined, and the feelings of the patient may be re- 



INFLAMMATIONS OF THE AIR PASSAGES, &C. 255 



lieved, and probably tlie decline of the disease accele- 
rated, or suppuration averted, by some of the antiphlo- 
gistic remedies ; by repeated doses of such laxative me- 
dicine as may cause a decided derivation from the 
upper parts of the body, and by frequent doses of saline 
diaphoretics, or of preparations of antimony (even by 
full vomiting in the very beginning, as recommended 
by Cullen) where there is an obvious tendency to sweat- 
ing. In cases which threaten to be unusually urgent, 
bloodletting, general or local (especially the former), 
may sometimes be very properly employed, and if used 
at all, in the view of arresting suppuration, or exten- 
sion to the glottis, must be carried to an extent propor- 
tioned, not to the size of the organ inflamed, but to the 
violence of the inflammatory fever. When the inflam- 
mation in the throat is severe, but the fever not so high, 
early blistering the throat appears sometimes very efl*ec- 
tual. During the height of the inflammation, gargling 
the throat is a precarious remedy, and frequently sipping 
demulcent or slightly astringent drinks, or inhaling the 
vapour of hot water, is usually better. 

In some cases of unusually severe affection of the 
tongue, the assiduous use of very cold or iced water, has 
seemed decidedly beneficial. 

When the inflammation is becoming chronic, astrin- 
gent, and even stimulating gargles are of use ; but more 
efl'ectual local remedies are the insufflation of finely 
powdered alum, repeatedly in a da.y, or the application, 
once a day, or seldomer, of a strong solution of limar 
caustic. In such cases there is often a feeble state of 
the general system, and a more tonic, although not sti- 
mulating regimen ; and the use of Bitters, Quinine, and 
mineral acids, or of preparations of steel, is usually 
advised. ^ 



256 OUTLINES OF PATHOLOGY AND PRACTICE. 



When tlie inflammation lias passed into ulceration, and 
this shews no healing tendency, by far the most effectual 
local remedy is touching the ulcer, once in two or three 
days, with lunar caustic. In such cases it becomes a 
question, — according to the constitutional affection, which 
is judged to be the chief cause of the unfavourable pro- 
gTOss of the local disease, — what remedy of the class of 
alteratives should be tried. In truly Syphilitic cases, 
in most constitutions, previously sound, and under pre- 
cautions to avoid cold during and after it, a mild Mer- 
curial course is more effectual than any thing else ; and 
the same may be said of many cases of ulceration, threat- 
ening to affect the larynx, but which cannot be traced 
to syphilis as their origin ; in those who have suffered 
from mercury, or are of scrofulous habit, Sarsaparilla, 
and other vegetable diaphoretics, and the preparations of 
Iodine, are the best auxiliaries to the cautious regimen 
and mild but nourishing diet, which are always advis- 
able. 

In cases which take the form of Diphtherite, it has 
been thought by some that the local applications already 
mentioned, of alum and of lunar caustic, have prevent- 
ed the extension of the disease into the larynx ; when 
the larynx has become affected, the remedies for the 
species next to be considered — among others calomel 
with opium, if early used — have sometimes seemed ef- 
fectual ; and in some such instances, where the state of 
the constitutional symptoms has apparently demanded 
the general remedies for typhoid fever, the disease has 
abated under their use ; but the influence of no remedies 
over that form of the disease is either powerful or well 
ascertained. 

Much may often be done to lessen the tendency 
to inflammation of the fauces (which generally abates 



INFLAMMATIONS OF THE AIR PASSAGES, &C. 257 



spontaneously as life advances) by tlie tonic regimen 
generally, and particularly by the habitual prudent 
application of Cold, locally or generally. 

Sect. II. — Of the Cynanche Laryngea and Trachealu, 

These two names denote in fact the same disease, 
known by the symptoms clearly laid down by Cullen — 
the " respiratio difficilis, inspiratio strepens, vox rauca, 
tussis clangosa," which, once fairly made objects of at- 
tention, can never be mistaken, and the concurrence 
of which with inflammatory fever, certainly indicates 
that the larynx and upper part of the trachea are af- 
fected with inflammation, threatening death by suffoca- 
tion, and often going on to fatal termination wdthin 
two, three, or four days. 

The distinction of the two has been founded chiefly on 
these circumstances, that the Cynanche Trachealis, or 
Croup, which was first accurately described, is nearly 
confined to infants and young children, — that it is un- 
attended with difficulty of swallowing, — and that it is 
fatal chiefly by the formation of an inflammatory exuda- 
tion on the mucous membrane of the Larynx and Tra- 
chea ; whereas the Cynanche Laryngea is described as 
attended with difficult deglutition (indeed often super- 
vening on the C. Tonsillaris) as affecting adults, and as 
fatal by thickening of the membrane at the glottis, or by 
effusion of serum (or of pus) behind it, constituting the 
oedema glottidis, — not by the formation of a false mem- 
brane, nor by any change lower than the glottis. It is 
important to observe these distinctions, and particularly 

R 



258 



OUTLINES OF PATHOLOGY AND PRACTICE. 



to attend to the usual limitation of the dangerous re- 
sult of the disease in adults, nearly to the glottis ; but 
they are not so uniformly observed as to enable us to 
form separate species of the disease, as occurring in 
children and in adults. 

It is important also to remember, that, in most cases, 
and particularly in children, this inflammation is only a 
part of a more general Bronchitis or catarrh, on the 
symptoms of which those of the Croup often gradually 
supervene, although in other cases the attack is sudden 
and violent. 

The attacks of Dyspncea in this disease are liable to 
obvious and sudden exacerbations and remissions, shew- 
ing that they depend in part on spasm, occasionally 
supervening on the inflammation. There are many 
cases in infants of purely spasmodic constriction of the 
glottis, and crowing respiration, chiefly observed after 
sleep, of short duration, unconnected with the other 
symptoms of croup, and which certainly depend on a 
peculiar irritation of the laryngeal nerves (recurrents) ; 
sometimes tumours compressing or stretching them, but 
which are not a febrile or inflammatory disease. 

Although often extremely rapid in its progress, this 
disease sometimes assumes quite a chronic form, in con- 
sequence either of thickening of the membrane to a cer- 
tain point, where it becomes stationary, or of the growth 
of tumours of various kinds (sometimes malignant) in 
connection with the inflammation, or of the formation 
and continuance of a false membrane in the larynx and 
trachea. In the last case it sometimes happens that 
after the inflammation has subsided, this membrane is 
separated and detached by expectoration. 

This disease is generally produced by a combination 



INFLAMMATIONS IN THE AIR PASSAGES, &C. 259 



of cold with moisture, and is hence observed to be re- 
markably more frequent in low moist situations than 
in higher grounds, ^ and in wet weather than very cold. 
It. is more rapid in its progress, and more fatal, — proba- 
bly because the false membrane forms more rapidly, — 
in very young than in older children, but is seldom 
seen in those that are still on the breast. The mor- 
tality from the disease in children under the age of five, 
has been stated, and probably not exaggerated, at 1 
in 2. 

It is remarkably prevalent in some families, more 
than others, and extremely apt to recur in the same in- 
dividual ; if the recurrence or relapse is within a very 
few days only, it is very often fatal ; but if the patient 
fairly recovers the first time, the subsequent attacks are 
very generally milder. 

The course of the disease is so rapid, and the amount 
of inflammatory effusion near the glottis, which may be 
fatal, is so small, that the antiphlogistic remedies in a 
well-marked case must be urged in rapid succession. 

General bloodletting, particularly in adults, appears 
often to arrest the disease very satisfactorily, if employ- 
ed within a few hours after the first marked attack ; 
but at a later period it seems often nearly inefficacious. 
In young children, leeches act as a general evacuation, 
and are most conveniently applied to the feet. After 
the time for advantage from general bleeding is over, re- 
peatedly leeching the larynx, in older children, or in 
adults, appears often decidedly beneficial : with this, and 
in cases of weakness, or when the fever is mild, without 
this, full vomiting, early brought on, and followed by 
full purging, is often efi'ectual. Thus by Tartar Eme- 
tic, Ipecacnan, Jalap, and Calomel, given so as to op% 



2G0 OUTLINES OF PATHOLOGY AND PRACTICE. 



rate both ways, and in qnick succession, many are cer- 
tainly saved. Great care to avoid cold during and after 
the operation of these medicines is very important, and 
the warm bath appears often a useful auxiliary. 

In some cases, effectual relief follows immediately 
after full vomiting, and in these, it may be presumed, 
that the dyspnoea was in a great measure the effect of 
spasm of the muscles of the glottis. In the more 
severe cases, vomiting is usually, though not uni- 
formly, produced with difHculty, and only by large 
doses of Emetics, and in these, more effectual relief 
follows the full operation of purgatives. In a few 
cases, when the dyspnoea continues, after these eva- 
cuations have been carried as far as the strength of the 
patient appears to admit, it abates under the use of 
repeated doses of Calomel with Opium; but whether 
any specific effect is produced in such cases by the 
Mercury, is doubtful. In such cases, there is usually no 
salivation ; and when full salivation has taken place, it 
has often appeared useless. In advanced cases of this 
kind, when the pulse has become feeble, and the skin 
cool, wine in small quantities has appeared useful. 
Recoveries have taken place after a slight degree of 
lividity of the lips, and of intermission of the pulse, and 
of delirium or coma (as in other cases of approaching 
death by asphyxia) have taken place ; but these symp- 
toms are most generally fatal. 

When such remedies have been fairly tried, and 
failed, Tracheotomy is the only remaining resource, 
and if to be tried, ought not to be delayed. In the 
case of children, this has hardly ever been successful, 
but in adults frequently. The reason obviously is, that 
in the former case, the inflammation very generally ex- 



INFLAMMATIONS IN THE AIE PASSAGES, &C. 261 



tends to the broiichiee,— even tlie preeternatural mem- 
brane sometimes reaches thus far, and much muco-puru- 
lent effusion exists in the smaller branches : whereas 
in adults, particularly in cases of a somewhat chronic 
character, the impediment to respiration in this disease 
is often nearly confined to the glottis. It must always 
be observed, that the effect of an artificial opening in 
the Trachea, vv^hich cannot be instinctively closed, as 
the glottis is, during a part of the act of coughing, and 
cannot therefore cause the requisite alternate compres- 
sion and expansion of the air within the air passages, 
is to suppress expectoration more or less completely. 
By careful examination of the mode of breathing, and 
of the chest during breathing, and attention to the 
marks of the respiratory actions afterwards to be no- 
ticed, we can often judge pretty confidently whether the 
air which has got through the glottis passes freely into 
the air-cells, and expands the lungs, or whether it is 
much obstructed in its passage through the bronchiee ; 
and it is in the former case only, that we can hope for 
benefit from the operation. 

The name Cynanclie Parotidcea has been given to an 
inflammation affecting either the parotid glands, or the 
lymphatic glands in their immediate neighbourhood, at- 
tended with febrile symptoms, and spreading at times 
epidemically, — therefore no doubt of specific character, 
— which has generally appeared to be devoid of danger, 
but on which the curious observation has been repeatedly 
made, that the rapid abatement of the inflammation at 
this part has been followed by symptoms of inflammation 
at the testes, or at the mammse, or by headache, deli- 
rium, convulsions, with or without scanty urine and 



262 OUTLINES OF PATHOLOGY AND PRACTICE. 



Anasarca. This observation has led to the belief that 
this Cynanche Parotideea ought not to be interfered with 
farther than by the antiphlogistic regimen, and mild 
laxatives, and diaphoretics ; and that more active de- 
pleting remedies should only be employed when such 
metastasis of inflammation to other parts shall have taken 
place. But the symptoms last mentioned, indicating 
acute disease of the brain, and of the kidneys, have been 
so often observed after the Cynanche maligna, as to 
warrant the suspicion, that the cases described as me^ 
tastases of Cynanche Parotidsea, to those parts, were 
really examples of one form of that more dangerous dis- 
ease. 



Sect. III. — Of the Bronchitis, 

It is now generally allowed, that the candid confession 
of Cull en, that our diagnostics do not serve to ascertain 
exactly the seat of the disease, when inflammation at- 
tacks the viscera of the thorax, or the membrane lining 
the interior of that cavity, need no longer be made ; and 
although the same antiphlogistic treatment is in the 
first instance applicable to all, when occurring in their 
simple and acute form, yet there are varieties in the 
course to be expected, and in the application of reme- 
dies, which make it of the utmost importance to consider 
separately the inflammations of the bronchial membrane, 
of the substance of the lungs, of the pleura, and of the 
heart and pericardium. 

We consider, under the head of Bronchitis, the cases 
described under the different names of Catarrhus, Bron- 
chitis, Peripneumonia notha, and the varieties of these 



INFLAMMATIONS OF THE AIK PASSAGES, &C. 263 



enumerated by different authors ; we have to notice the 
very frequent compHcation of this inflammation with. 
Spasm, in Asthma and in Hooping-cough, and its fre- 
quent occurrence, with peculiar febrile symptoms, in the 
form of an Epidemic, to which the name Influenza is 
given ; and to enumerate likewise the different diseases, 
febrile and non-febrile, of which inflammation of the 
Bronchiee is either an essential constituent, or a frequent 
and important concomitant. 

In its simplest and mildest form, this is perhaps the 
most frequent inflammatory disease produced by exposure 
to cold or wet, in the circumstances favouring the effect 
of these morbific causes, in this climate, — consisting es- 
sentially in inflammation commencing in the mucous 
membrane of the nose, and rapidly extending along the 
air-passages into the bronchiae, — marked by Coryza, — of- 
ten Epiphora, hoarseness, more or less of straitened res- 
piration, and cough, at first dry, but soon attended with 
expectoration, which is mucous, sometimes scanty and 
viscid, sometimes copious and frothy, often gradually be- 
coming puriform, but untinged with blood. With these 
symptoms there is general fever, usually rather slight, 
often much headache and pain felt in the chest, but 
chiefly or only on coughing, and referred to the centre 
of the chest rather than either side. On examination 
of the chest (if previously healthy), it is found to sound 
naturally on percussion, and to expand equally on inspi- 
ration on both sides, and the natural sound of respiration 
is heard pretty generally, although rendered harsher, 
and obscured in some parts by the admixture of " bron- 
chial rales," which, however, in the early stage of most 
cases, are heard only partially^ and only over the situar- 
tion of some of the larger bronchiae. : : 



264 OrXLINES of rATIIOLOGY AND PRACTICE. 



These are at first the dry rales — sibiloiis and sonorous, 
— or the whistling, cooing, and snoring" sounds ; 
afterwards the moist, suh-crepitons and mucous rales, — 
which convey the impression of air raising bubbles in a 
fluid as it passes along the tubes, and differ only as these 
bubbles are more numerous and smaller, or less nume- 
rous and larger ; — the latter graduating into the tracheal 
rale of moribund persons. 

If no cause of aggravation or renewal of the disease 
(particularly fresh exposure to cold, muscular exertion, 
full diet, or stimulating liquors) be applied, this inflam- 
mation usually subsides in a few days, the expectoration 
becoming more free, and the sputa somewhat thicker 
and more opaque, and examination of the chest shewing 
that the bronchial inflammation has travelled downwards 
to the minute branches only in a part of the lungs. But 
in many persons the complaint is very easily aggravated 
or renewed ; and its importance depends essentially on 
two causes ; firsts Its tendency, especially in older per- 
sons, to assume the chronic form ; and, secondly^ Its 
frequent complication, at all ages, with more or less of 
spasmodic asthma, shewn by the frequent exacerbations 
of the dyspnoea, and by the wheezing sound (cum sibilo 
strepente) of the respiration during these. 

These symptoms, as well as the peculiar sound, and 
long continuance of the fits of coughing in such persons, 
we have no doubt, depend on a spasmodic action of the 
bronchipe, the muscularity of which has been lately well 
illustrated by the galvanic experiments of Dr Williams 
on the lungs of animals just killed. Indeed, it seems 
inevitable, from what we know of the Keflex Function 
of the spinal cord, that more or less of spasmodic action, 
both of these muscles and of the muscles moving the 



INFLAMMATIONS OF THE AIR PASSAGES, &C. 265 



chest ill Respiration, should be excited by inflammation 
of this membrane ; but in certain constitutions this spas- 
modic action, in both sets of muscles, as shewn by the 
dyspnoea and wheezing, and by the violent and long- 
continued fits of coughing, is greatly in excess. 

Such distinctly spasmodic paroxysms most generally 
commence during or after the soundest sleep, and are 
often excited by some peculiar cause, such as disor- 
dered stomach, or muscular exertion ; or by sudden 
changes of weather, or by certain states of the atmosphere, 
varying in different persons, dry and rare air in some, 
dense and moist in others, — more frequently by pure 
and cool air than by air loaded with smoke and carbonic 
acid. 

These two peculiarities of this inflammation are very 
frequently seen in the same individual, and the tendency 
to both is remarkably observed to be hereditary. 

It is in such persons also, that the disease sometimes 
puts on its more acute and violent form, i. e, the fever 
becoming high, the dyspnoBa and noise of respiration ur- 
gent, and the natural respiratory murmur on both sides, 
and most parts, of the chest being much obscured by the 
rales, indicating that the inflammation has spread ex- 
tensively on the membrane. 

In such cases of violent Bronchitis, the diagnosis from 
Peripneumony, with or without Pleurisy, becomes im- 
portant, and is generally marked pretty distinctly by the 
absence of pain on either side, or of any stain of blood 
in the sputa, by the sonorous respiration, and the bron- 
chial rales, heard chiefly on expiration, and pretty uni- 
formly on both sides of the chest, and by the expansion 
of both sides on inspiration, and the sound on' percussion 
in both, continuing natural. The diagnosis is remark- 



266 OUTLINES OF PATHOLOGY AND PRACTICE. 



ably aided, likewise, by the frequent exacerbations and 
remissions of tbe dyspnoea, the former of which, in the 
cases where there is most of the spasm, take place 
chiefly in the morning after sleep, — in those where in- 
flammation predominates, chiefly in the evenings, — the 
remissions being generally marked by free expectoration. 

When neglected in the outset, or when occurring in a 
feeble habit, or complicated with previously existing or- 
ganic disease, this acute Bronchitis is not unfrequently 
fatal. The fatal event is preceded, as may be gathered 
from what was formerly said, by increase of the dys- 
pnoea, with failure of the circulation, soft, often irregular 
pulse, coldness, lividity, delirium or stupor ; — as describ- 
ed in the accounts of the Peripneumonia notha and of 
the " Catarrhe Suff'ocant." And the appearances on dis- 
section are characteristic, — ^the bronchial membrane red 
and thickened, the bronchia?, especially the smaller 
branches, clogged with muco-purulent matter ; the sub- 
stance of the lungs, chiefly the depending portions, gorged 
with blood, and pouring out much serum when cut 
and pressed, but nowhere condensed so as to sink in 
water, nor mottled by exudation of solid lymph into the 
air-cells, as in hepatization of the lungs, nor coated on 
their surface by exudations of lymph. 

It is always to be borne in mind that there is a danger 
attending the Bronchitis, from the obstruction of the 
blood descending from the head during the fits of cough- 
ing, particularly when these are violent. Hence arise 
the convulsion fits, often complicating the hooping- 
cough ; and the severe headaches (introduced by Syden- 
ham into his definition of Peripneumonia notha) and 
attacks of apoplexy or palsy, often seen as eflects of this 
disease in old persons. 



INFLAMMATIONS OF THE AIR PASSAGES, &C. 267 



Passing, as it more generally does, into the chronic 
form, with little fever, but habitual cough and expecto- 
ration, sometimes of opaque mucus only, sometimes of 
perfect pus, sometimes without, but more frequently 
with, occasional recurrences of the spasmodic asthma, 
the Bronchitis demands careful attention on account of 
its consequences and complications. 

1. Besides giving always a predisposition to more 
acute attacks of the same kind, it becomes complicated 
occasionally, although not nearly so often as might be 
expected, with the Peripneumony, next to be considered. 

2. Perhaps more frequently it is complicated, espe- 
cially in persons advanced in life, with haemoptysis, and 
that state described as apoplexy of the lung, depending 
on effusion of entire blood into parts of its substance. 

3. In young persons, if unusually violent, or frequently 
renewed, it sometimes becomes attended, not only with 
purulent expectoration, but with perfect hectic fever; 
and death may take place, after long emaciation, with 
external circumstances exactly resembling Phthisis, al- 
though no morbid deposition has taken place in the sub- 
stance of the lungs. 

4. The repeated recurrence of the disease, especially 
with asthmatic paroxysms, leads to the state called 
Emphysema Pulmonum, in which the septa of many of 
the minute air-cells are broken down, and they coalesce 
into larger irregular cavities, — air escapes into the cel- 
lular substance immediately beneath the pleura, and 
sometimes forms bullso on its surface, — and the whole 
lung becomes more voluminous, of lower specific gravity, 
and, by reason of the enlargement of the cells, approxi- 
mates to the structure of the lungs of reptiles ; and is 
rendered unfit for the rapidity of mutual action of the 



268 OUTLINES OF PATHOLOGY AND rPvACTlCE. 



air and blood wliich is requisite in warm-Llooded ani- 
mals, at least under any excitement of the circulation. 
This state, therefore, necessarily implies habitual short- 
ness of breath ; and it is very often indicated, as an ac- 
companiment and result of habitual bronchitis and 
asthma, by the unnaturally arched and very resonant 
chest, with faintness of the natural respiratory mur- 
mur, and constant admixture of the bronchial rales, 
chiefly in expiration. A certain degree of this change 
of the lungs, as Dr Lombard has shewn, takes place very 
frequently, and apparently from slight causes, in advanced 
life, when the texture of the lungs, particularly to- 
wards their external surface, becomes comparatively 
bloodless and brittle ; but in younger persons it pro- 
bably takes place only as a consequence of the bronchial 
inflammations connected with Spasm, — i. e. Asthma and 
Hooping-cough, — and in such subjects no doubt admits 
of spontaneous cure, when recurrence of the inflamma- 
tion is prevented. 

In cases of chronic Bronchitis, when fatal, ^ye expect 
to And, on dissection, not only this condition of the lungs, 
and the muco-purulent eff'asion into the bronchise, but 
occasionally dilatation of the bronchise (chiefly, however, 
in parts previously condensed by inflammation), and 
very frequently serous eflusion into the cells of the lungs. 

5. Bronchitis and Asthma are not unfrequently com- 
plicated vvith tubercular deposition, and pass into regular 
Phthisis. This is generally recognised, after a time, not 
merely by the hectic fever (which is an equivocal indi- 
cation, as appears from what has been already said), but 
by the indications of consolidation and subsequent ulce- 
ration of the upper lobes of the lungs, to be afterwards 
described, — subject, however, to some ambiguity, from 



IXFLAMMATIOXS OF THE AIR PASSAGES, &C. 269 



the rare occurrence of condensed lung and enlarged 
broncliise, independently of tubercles and ulcers. 

6. After lono -continued Broncliitis, with asthmatic 
paroxysms, and especially after emphysema of the lungs 
has resulted, there is necessarily an habitually slow move- 
ment of the blood through the lungs, from the impedi- 
ments to that mutual action of the air and blood, which 
is known to be, in one way or other, an auxiliary cause 
of motion of the blood there. From this naturally re- 
sult two consequences, both frequently very obvious, and 
of great importance in the advanced stages of these com- 
plaints ; — in those strongly disposed to bronchitis, seen 
even in childhood, more frequently in advanced life ;— 
enlargement and hypertrophy of the right side of the 
heart, known by pulsation at the Epigastrium, and some- 
times in the jugular veins ; and congestion, enlarge- 
ment, and gradual change of the texture of the liver ; 
particularly the granular degeneration of the liver, to 
be afterwards noticed, or in more unhealthy subjects 
other forms of organic disease. And in this state of 
the venous circulation, we can easily perceive that Drop- 
sical effusion may be very readily produced, and espe- 
cially that, as often happens, it may be repeatedly caused 
by fresh attacks of Bronchitis, hurrying the circulation, 
and farther impeding the arterialization and transmis- 
sion of the blood in the lungs. 

While habitual Bronchitis gives this natural predis- 
position to various organic lesions, it is easy to perceive 
that a predisposition to the Bronchitis itself must natu- 
rally result from previously existing organic disease, 
particularly from such as impedes the transmission of 
blood through the left side of the heart ; and therefore 
that it should be a nearly constant attendant on the most 



270 OUTLINES OF PATHOLOGY AND PEACTICE. 



common organic diseases of the heart, and that the con- 
comitant paroxysms of asthma should be very readily ex- 
cited in such persons. 

The prognosis in cases of Bronchitis must, of course, 
depend partly on the violence, and particularly the 
general extension, throughout the lungs, of the inflam- 
mation ; partly on the degree in which the constitution 
appears liable, from hereditary peculiarity, or from re- 
peated recurrence, to the attacks of the disease ; and 
partly on the degree of complication, in any individual 
case, with those accompaniments or consequences which 
have now been enumerated. 

In the advanced stage, the worst symptoms are in- 
creasing dyspnoea, suppressed expectoration, and sinking 
circulation ; and when delirium comes on, the case is 
almost uniformly hopeless. 

Two contagious, but not eruptive diseases, consist es- 
sentially in Bronchitis, with certain accompaniments ; 
and both the Prognosis and Practice in them are mainly 
reo'ulated bv the extent of the bronchial inflammation, 
viz. the Pertussis, usually seen in children, and the In- 
fluenza, often fatal to persons advanced in life. There 
is no doubt of the contagious property of Pertussis, al- 
though the fever does not shew, in that disease, any of 
the typhoid symptoms usually attending contagious 
febrile diseases, nor does it appear that the contagion 
attaches itself to fomites. The Influenza, or contagious 
Catarrh, has been often epidemic in modern Europe, 
and extends itself so rapidly, and afl^ects such vast num- 
bers of people within a very short time, that it has been 
reasonably suspected that its propagation depends on an 
" atmospheric influence," rather than on contagion. 
The danger in both these diseases depends mainly on 



INFLAMMATIONS OF THE AIR PASSAGES, &C. 271 



tlie extent of broncliial inflammation attending them, 
and perhaps the only peculiarities in their pathology 
which have a practical bearing, are the following : — 

As to the Hooping-cough, it is necessarily an inflam- 
mation of many weeks' duration, of chronic character 
for the most part, but in its beginning acute, and after- 
wards easily aggravated into an acute form; and attended 
always with spasmodic action, which gradually becomes 
habitual, and like other spasms, may then be favourably 
aff'ected by medicines acting on the nervous sytem, and 
by a change of scene and mode of life. 

As to the Influenza, it is always attended by, or forms 
part of, a constitutional fever, of which a remarkable 
degree of debility is an essential part, and which, from 
that cause, although always of short duration, and hardly 
ever shewing strictly typhoid symptoms, is often very 
dangerous to old or feeble persons. 

The danger of Hooping-cough often depends on Con- 
vulsions, occurring during or immediately after the fits 
of coughing, and may often be averted in such cases by 
early leeching and purging ; excessive evacuations, how- 
ever, in this, as in other spasmodic diseases, only aggra- 
vating the symptoms, particularly in the later stages. 
But many cases of the fatal termination of Hooping- 
cough, and probably almost all of Influenza, when un- 
complicated, depend on niuco-purulent eff'usion, extend- 
ing downwards to the minutest branches of the bronchise, 
as is shewn in the advanced stage, by the general sub- 
crepitous rale, chiefly in the lower and back part of both 
sides of the chest. 

Again, Bronchitis is a very common complication of 
Continued Fever, — in which it appears as an accidental 
accompaniment, arising at any period of the disease ; 



272 OUTLINES OF PATHOLOGY AND PRACTICE. 



and it is a uniform and essential constituent both of 
Small-Pox and Measles, and constitutes very often a 
great part of the danger of these diseases. But of these 
symptomatic cases of Bronchitis it will be necessary to 
treat more fully afterwards. 

In the treatment of the intense Acute Bronchitis, 
whether attacking a person previously healthy, or su- 
pervening on other disease, or on the more chronic 
form, early general Bloodletting, and, in tolerably young 
and strong persons, repeated bloodletting, is often es- 
sentially important, giving relief in circumstances of 
distress which are beyond the reach of any other re- 
medy. But it is often, especially if delayed for even 
a day or two, not observed to exert any such decided 
power over the disease : and in all cases it is to be 
expected that the disease will take the chronic form, 
and that this remedy will, after a time, become use- 
less, or even injurious ; because, in the advanced stages 
of the disease, when there is much accumulated mu- 
cus in the bronchi as, and the pulse becomes feeble, the 
requisite expectoration is easily suppressed, dyspnoea 
aggravated, and probably serous effusion, particularly 
into the cells of the lungs, promoted by any powerfully 
weakening cause. These facts necessarily limit the use 
of general Bloodletting to the first few days of decided 
attacks or renewals of Bronchitis, when the febrile symp- 
toms are recent, the pulse firm, and the fits of coughing 
excite pain of breast and head , and the age and previous 
diseased state of many patients limit it still farther. The 
local Bloodletting is often safe and beneficial when the 
general would ba hazardous ; and both are sometimes 
demanded by the effects above mentioned of the disease 
in the head, or by threatening of these, — pain, giddiness, 

8 



INFLAIVIMATIONS OF THE AIR PASSAGES, &C. 273 



impaired vision, or flushing, when thej would not be 
thought necessary on account of the pectoral disease it- 
self. The effect of Blistering is often distinctly benefi- 
cial, but caution is required, particularly in young chil- 
dren of feeble habit, lest the blistered surface, particu- 
larly if the plaster has been applied more than a few 
hours, should ulcerate or even slough. Repeated Sina- 
pisms, or rubefacient Liniments, assiduously applied, are 
of use. 

Moderate purging, as part of the general antiphlogis- 
tic regimen, is proper ; but there is a danger of the de- 
bility attending frequent and watery evacuations by 
stool diminishing the expectoration, the maintenance of 
which, in the later stages, is very important. But there 
are other remedies in the more chronic or advanced 
Bronchitis, whether idiopathic or symptomatic of the 
diseases mentioned above, the prudent use of which ap- 
pears frequently to be very usefuL These are, 

1. Emetics, given repeatedly, particularly to young 
children, in whom their operation is very generally at- 
tended with a flow of attenuated mucus in the bronchige, 
facilitating expectoration. Where, however, there is 
fulness of blood, or obvious determination to the head, 
other evacuations, very often leeching, should precede 
the emetics, lest convulsions should take place under 
their action. 

2. Expectorants, particularly, in the earlier stages, 
those which are nauseating,— ^antimonials in small, fre- 
quently-repeated doses, or, if these appear to depress the - 
strength too much, small, frequently-repeated doses of 
Ipecacuan, in powder or wine, and the inhalation of 
the vapour of water ; afterwards, when the strength is 
more impaired, and especially if there be dropsical ten- 

s 



274 



OUTLINES OF PATHOLOGY AND PRACTICE. 



dency, Squill, with Ammoniac, or other gum- resins, and 
preparations of Ammonia, seem more distinctly to pro- 
mote expectoration. 

3. In the more advanced stages, when there is little 
fever or pain, but much effusion into the bronchise, 
astringents, which seem to diminish that effusion, appear 
sometimes the most effectual remedies ; sometimes the 
preparations of Lead, Zinc, or Alum ; sometimes some 
of the bitters, such as Quinine, Quassia, Seneka, and 
the Mineral Acids ; sometimes Cantharides or Copaiba, 
or other resins, or the inhalation of Chlorine gas, much 
dihited, 

4. In combination, or alternated with these reme- 
dies, Opiates, almost from the beginning, but in general 
in small doses, lest they check expectoration, are tem- 
porarily palliative, and evidently conduce to the favoura- 
ble termination ; and when the Asthmatic tendency is 
obvious, and no acute febrile symptoms present, ^ther, 
or the fumes of Stramonium, often decidedly assist the 
opiates. 

5. In the advanced stages, when the pulse becomes 
feeble, and expectoration difficult, stimulants, particu- 
larly small frequent doses of Wine, Alkohol, and Am- 
monia, are not only admissible, but often signaliy bene- 
ficial. 

Throughout almost the whole of the disease, warm 
clothing, a regulated temperatm-e, as near to 60' of 
Fahrenheit as possible, and care to avoid all muscular 
exertion, and all causes that can hurry the respiration, 
are of the utmost importance, and deviations from 
these rules often decidedly injurious ; but in the later 
stages, when the inflammatory tendency has subsided, 
when the breathing is not habitually difficult, and the 



INFLA]VmATIONS OF THE AIR PASSAGES, &C. 275 



appetite returning, and especially if the complaint is 
partly spasmodic, exposure to the open air, even at a 
lower temperature, with exercise and change of scene, 
become often useful. 

In some advanced cases, attended with the tendency 
to stupor. Blisters to the head, or other means of ex- 
citing the sensibility, are more effectual than any other 
remedies, particularly as expectorants ; but this is more 
frequently observed in the Bronchitis symptomatic of the 
strictly febrile diseases, than in the idiopathic form. 

Sect. IV. — Of the Feripneumony. 

It is certain, that there are many cases of the Bron- 
chitis lasting in the chronic form for years, and occa- 
sionally taking the acute form, in which the substance 
of the lungs is never inflamed ; and cases of Feripneu- 
mony, in which the bronchisG are unaffected, at least 
until the last period of the disease ; but the combination 
of the two diseases is by no means so rare as has been 
stated, — and while many cases of the Feripneumony be- 
gin suddenly, with a well-marked febrile paroxysm, and 
without previous catarrh or bronchitis, many others 
supervene gradually on that disease, with slow aggrava- 
tion of existing febrile symptoms and dyspnoea. The 
pathological distinction is obvious and important, but 
the Diagnosis, during life, at least in the early stage, is 
often difficult. 

The Feripneumony occurs at all ages, but most fre- 
quently below the age of five, and above that of fifty. 
It seldom attacks both lungs at once, and probably never 
equally, and hence differences are usually perceptible in 



276 OUTLINES OF PATHOLOGY AND PRACTICE. 

the condition of the two sides of the chest, even early 
in this disease. The expansion of the affected side is 
some^Yhat less, and the sound on percussion gi'adually 
becomes dull (although both these symptoms are much 
less obvious than in the Pleurisy) ; and the sound of 
Respiration, as compared with the other side, becomes 
obscured or altered. It is obscured, by the admixture 
of the " crepitous rale,'" that modification of the moist 
rale fp. 26^1), in which the bullte formed by the passage 
of air through the tubes appear to be most numerous 
and smallest; or it is altered to the character which is 
designated by the terms " harsh'' and bronchial," 
I, e. it conveys the impression of air passing along un- 
yielding tubes (imitated, therefore, by blowing through 
the tube of the Stethoscope), rather than of air passing 
into and expanding a soft cellular texture. Ultimately, 
in some cases, it is altogether suppressed. It must be 
allowed, however, that the latter distinctions, particularly 
if rales are present, are often perceived with difficulty ; 
and as to the crepitous rale, although very characteristic 
when distinctly heard, it is only observed in some cases, 
and seldom for many hours together. 

Besides these changes in the respiratory sounds, there 
is also, when tlie limg becomes condensed by inflamma- 
tion, a resonance of the voice at the part fhroncho- 
phonii J often pretty extensive, such as, in the natural 
3tate, is not heard in the chest, or heard only over the 
largest bronchiee, — chiefly under the right clavicle. 

These alterations of the sounds in the chest, in cases 
of Peripneumonyy are chiefly noticed over the middle 
and lower lobes of the limgs ; the upper lobes, although 
by no means exempt from the disease, being less fre- 
quently the subjects of it. 



INFLAMMATIONS OF THE AIR PASSAGES, &C. 277 



111 many cases the inflammation of the substance of 
the kmgs extends to the Pleura pulmonalis, and even 
to the costalis ; and then the disease is very generally 
farther marked by stitch in the side, by more decidedly 
imperfect expansion of the side in inspiration, and rapid 
suppression of the respiratory murmur. 

In a large proportion of cases, the Peripneumony is 
farther indicated by characteristic changes in the sputa ; 
they acquire increased tenacity and translucency (in the 
early stage), and they become stained (not streaked) with 
blood, whereby they acquire various unnatural colours, 
bright yellow or greenish, but more generally various 
shades of brownish-red or rust colour, gradually deepen- 
ing as the disease advances. 

These local symptoms of Peripneumony are attended 
with cough and dyspnoea, varying considerably in inten- 
sity, usually with some degree of obtuse pain of chest, 
and with fever often distinctly inflammatory, but not 
unfrequently assuming more of the typhoid type than 
that of any other idiopathic internal inflammation ; the 
pulse is frequently soft, and there is much febrile op- 
pression and muscular debility, even in some cases dry 
tongue, delirium, and subsultus tendinum, when the pro- 
gress of the disease shews that there is no complication 
with truly typhoid or contagious fever. 

We know that these symptoms attend the effusion, 
first of serum, but soon afterwards of much fibrin, into the 
pulmonary cells, and the gradual conversion of a portion 
of lung into the state of hepatization formerly described ; 
that this takes place to very various extent, and with 
very various rapidity, probably most rapidly and exten- 
sively when this inflammation attacks persons in a feeble 



278 OUTLINES OF PATHOLOGY AND PRACTICE. 



state of health ; and that in some cases extensive hepa- 
tization is effected in a very few days, while in other 
cases, after these symptoms have made some progress, 
the inflammation subsides (chiefly under the antiphlo- 
gistic remedies), and the natural action and sounds of 
the part are gradually restored. 

When a portion of lung has been hepatized, the sub- 
sequent progress of the case is various. If the part af- 
fected be large ; if the patient be previously strong and 
plethoric j if the disease be attended by general bronchi- 
tis or other diseases, — this state of the lungs is attended 
with the change of symptoms formerly noticed, as indi- 
cating failure of the strength, along with increasing 
dyspnoea, and death takes place by Asphyxia, sometimes 
within the first week, before any ulterior change on the 
lungs has been effected. 

When the dyspnoea attending these changes is less 
urgent, the affected part of the lung frequently passes 
into that mode of suppuration described by Laennec as 
the third stage of hepatized lung, i. e. the lymph effused 
takes the form of pus, and although no circumscribed 
abscess is formed, the whole substance of the affected 
part assumes the appearance of sponge soaked in pus. 
In some cases even sloughing of the hepatized lung, 
without much change of its colour, ensues. In such 
cases the expectoration will naturally become purulent, 
and as we know that many cases of Pneumonia terminate 
favourably after copious purulent expectoration, we can- 
not doubt that one mode of restoration of the functions 
of hepatized lung (when the change is not very exten- 
sive) is by conversion into pus and expectoration by the 
air-passages, of lymph which has obstructed the cells. 



INFLAIVBIATIONS OF THE AIR PASSAGES, &C. 279 



But many cases are fatal while this process of restora- 
tion of the internal state of the lung by suppuration is 
making partial progress. 

The recovery of a portion of inflamed lung, either by 
resolution, and, no doubt, absorption of part of the effused 
lymph, or through suppuration, is sometimes pretty 
distinctly indicated by the crepitous rale reappearing in 
a part where it had formerly been heard and disappear- 
ed, or where the sound of respiration had been bronchial, 
or been altogether suppressed. 

In other cases, chiefiy of slower progress, the portion 
of lung that has been condensed by inflammation becomes 
harder and drier, with a more uniformly grey colour ; 
and the patient either dies when it is in this state, or re- 
covers with a portion of lung permanently condensed, 
and impervious to air, which portion then acquires a dark 
colour from the usual black matter of the lungs, and 
sometimes, although rarely, passes into ulceration with- 
out any previous deposition of tubercles. When not ulce- 
rating, such condensed portions of lungs cause necessarily 
permanent shortness of breath, and give a predisposition 
to other chronic diseases of the chest, and often to 
dropsy. 

During the process of suppuration succeeding to Peri- 
pneumony, more or less of the febrile state generally 
continues, taking often somewhat of the form of Hectic ; 
and if the fever has not subsided within three weeks 
after the commencement of the disease, it may always 
be apprehended that ulceration, sometimes without, but 
much more frequently with, tubercular deposition, is to 
result. 

The tendency to Pneumonia is much greater in some 
individuals and families than others, and is greatly in- 



280 OUTLIXES OF PATHOLOGY AXD PEACTICE. 



jcreased by its once taking place. It is also remarkably 
increased, as is easily understood, by disease of tlie left 
side of the heart, and the prognosis is peculiarly unfa- 
vourable when it is .so complicated. 

In this disease, \vhen uncomplicated, and recognised 
from its commencement, the utmost contidence mav be 
placed in general Bloodletting, which should always be 
large, the hrst always continued until the breathing is 
distinctly relieved, and must almost always be repeated, 
sometimes four or six times, or even oftener ; in such a 
case, duly treated in this way, the only essential action 
of the prognosis is the day oi the disease when the treat- 
ment is commenced ; the remedy being often ineffectual 
when it is <:lelayed, more than two or three days froni 
the decided commencement of the disease. 

Although the case be complicated with others, and in 
a feeble constitution, if it be seen from the beginning, 
the o-eneral bleeding should hardlv ever be omitted ; 
but the quantity taken to produce an effect on it will of 
course be less. When it is seen only after some days, 
or when the symptoms continue, although mitigated, after 
the first bleedings, local bleeding may often be more 
advisable, because then a considerable extension of the 
inflammation is inevitable, and the depression of the 
strength by full general bleeding may be injuri'jus in the 
subsequent stages. 

In judging of the repetition of the bleeding, we must 
be guiled almost entirely bv the general symptoms, the 
state of the pulse, and the urgencv of the dyspnoea, 
cough and pain ; neither the appearance of the sputa, 
nor the sounds of the che-t. give much assistance. In 
particular, it is importanc to be aware that Auscultation 
may inn.icate continuance, and even extension, of the 



INFLAMMATIONS OF THE AIR PASSAGES, &C. 281 



disease in the lungs for a considerable time after tlie 
breathing has been effectually relieved, and the fever 
nearly or wholly subsided ; and that in these circum- 
stances farther bleeding is not required on account of 
these local signs ; although. careful watching, and repeti- 
tion of the bleeding on return of the dyspnoea, are ne- 
cessary. 

In some cases attended with typhoid fever, local 
bleeding only, alternated with wine and stimulants 
almost from the beginning, has been found effectual ; 
but in other cases where the symptoms have had that 
character, repeated (although moderate) general bleed- 
ing has been well borne. 

While placing our chief reliance on Bloodletting, it is 
right to use such auxiliaries as we believe to limit, as 
far as can be safely done, the quantity of this evacuation 
necessary to give a favourable turn to the disease. 
Blistering and purging, under the same cautions as in 
the Bronchitis, are to be employed ; and two other re- 
medies have been much recommended — Opium, espe- 
cially combined with Calomel, and the Solution of Tartar 
Emetic. Of these, the latter seems to be the most ge- 
nerally useful ; given in such doses as cause slight nausea, 
and repeated every two hours during the violence of the 
disease, it appears to act as a sedative on the circulation, 
and pretty certainly keeps down the fever and dyspnoea, 
and diminishes the quantity of blood required to be 
drawn. During the violence of the disease it is certain 
that much larger quantities than will usually (after bleed- 
ing) excite nausea, may be given without farther effect ; 
but whether it is of use to urge the use of the large doses 
of Avhich there is then this " tolerance," or whether 
this can always be done with safety, are more doubtful 



282 



OUTLINES OF PATHOLOGY AND PRACTICE. 



questions ; and while tliey are doubtful, that practice 
cannot be properly advised for general use in a case 
like this, where remedies of acknowledged power are 
recommended by all. When the pulse becomes feeble, 
and the skin cool, the Antimonials are contra-indicated 
in like manner as the loss of blood. 

The continuance of the cough and dyspnoea, and in- 
creasing frequency of pulse, with other indications of 
enfeebled circulation, are the symptoms which chiefly 
presage the fatal event of the disease. 

The chief use of Opium in this disease is where, after 
full bleeding and relief to the more urgent symptoms, 
the pulse continues frequent, with affection of the ner- 
vous system, restlessness, sleeplessness, even slight deli- 
rium — indicating a degree of the " Reaction after loss of 
blood," with cough and dyspnoea, of varying intensity, 
and which seem partly nervous or spasmodic. In such 
cases, sleep and relief to all these symptoms often suc- 
ceed its use, cautiously repeated. The addition of Ca- 
lomel, and of Ipecacuan, to correct its constipating ef- 
fects, and to promote perspiration and expectoration, is 
right ; but no reliance can be placed on the specific effect 
of Mercury in preventing or resolving the hepatization 
of lungs. When full expectoration is going on, its sup- 
pression by full doses of Opiates is always to be appre- 
hended. 

In many cases in the later stages, when the active in- 
flammation has subsided, the expectoration is promoted, 
and the strength and general feelings of the patient are 
benefited by the use of small quantities of stimuli, parti- 
cularly wine and the preparations of ammonia ; and in 
a few cases, neglected in the commencement, and where 
Jhe symptoms of the advanced stage (frequent and soft 



INFLAMMATIONS OF THE AIR PASSAGES, kc. 283 



pulse, dyspncea, general mucous rales, and sputa deeply 
and darkly stained) are urgent, recoveries take place 
under tlie use of such stimulating remedies exclusively, 
— ^the inflammation having subsided spontaneously with- 
out extending over much of the lung. 

Two peculiar forms of Pneumonia demand attention, 
rather, however, because they are cases in which we 
can hardly expect the ordinary remedies to be effectual, 
than because they admit of any successful peculiar treat- 
ment, viz. the case of inflammation going rapidly and 
surely to partial suppuration in the lungs, and the case 
of inflammation going to partial gangrene there. The 
first is always to be apprehended when symptoms of 
Peripneumony supervene on those of inflamed veins» or of 
suppuration in other parts of the body, e. g. after small- 
pox, and more especially after the amputation of a sup- 
purating surface, when it may be concluded that purulent 
matteT is circulating in large quantity in the blood. The 
second is almost exclusively observed in cases where the 
pneumonic inflammation is complicated with some other 
disease, acute or chronic, producing a feeble state of the 
circulation,— either the case just mentioned of previously 
existing suppuration, or typhoid fever, or some of the Ex- 
anthemata, or previous palsy, the action of mercury, &c. 
The presence of gangrene is denoted with certainty by 
the smell of the breath. We have reason to believe 
that recoveries have taken place from the advanced stage 
of aff'ections of both these last kinds (when more par- 
tial than usual) under the cautious use of stimulants. 

The frequent complication of one form of Pneumonia 
with continued fever, and some .of the Exanthemata, 
will be considered afterwards. 



284 OUTLINES OF PATHOLOGY AND PRACTICE. 



Sect. V. — Of Phthisis Puhnonalis, 

Without recurring to the question as to the 7node of 
connection of Inflammation of the Lungs with Tuber- 
cles, we next state the fact, that all the indications, 
general and local, of Bronchitis, or of a sub-acute or 
somewhat chronic Peripneumony, affecting chiefly the 
upper lobes of the lungs, are very often found, in per- 
sons who have the predisposition to scrofulous disease, 
in connexion with scrofulous tubercles in these parts of 
the lungs, either previously existing, or deposited in con- 
sequence of these inflanmiations, or both ; and that thus 
Phthisis Pulmonalis very frequently appears, in practice, 
as a consequence of these inflammatory diseases, usually, 
as might be expected from what was stated (at p. 201-2), 
of repeated attacks of them in their milder and more 
chronic form ; and that attacks of " intercurrent inflam- 
mation" form part of its usual history, and are indicated 
by the usual appearances on dissection. We admit, at 
the same time, that Phthisis sometimes shews itself and 
makes progress (chiefly in those most strongly predis- 
posed) without any indications of inflammation preced- 
ing or attending it. * 

We apprehend the aceession of Phthisis, of course 
chiefly in persons with scrofulous taint, or in scrofulous 
families, and in those whose mode of life has placed 
them in circumstances formerly stated as leading to the 
development of the Tubercular Diathesis : — we suspect 
it when the pulse becomes frequent and soft, with little 
jcough, little or no expectoration, and dyspnoea only felt 
on exertion, — when these symptoms continue and gra- 
dually increase with emaciation, and hectic accessions 



INFLAMMATIONS OF THE AIR PASSAGES, &C. 285 



gradually supervene ; we have more fear of it if there be 
attacks of haemoptysis, which is sometimes the first 
symptom that excites any alarm, and is more frequently 
seen to a considerable extent when tubercles are in their 
first stage, and the bloodvessels not yet obstructed by 
tubercular matter, than in the later stages of tuber- 
cular disease, when such obstruction has become gene- 
ral ; and we are confirmed in our opinion when we find 
a part of the lungs — generally the upper part of one or 
both lobes — shewing the marks which we know to go 
along with incipient tubercles, but which are nearly the 
same as those of partial peripneumony and bronchitis, 
viz. more or less of dulness on percussion, and some- 
times of imperfect expansion ; faint, or harsh, or bron- 
chial sound of respiration ; more than usual of resonance 
of voice ; the sound of the heart's action transmitted 
more distinctly than usual ; and an obstinate sub-crepi- 
tous or mucous rale. If tubercles are merely disseminated 
through the pulmonary substance, we know that they 
may exist to a great extent without causing these symp- 
toms ; but as they are generally deposited in clusters 
which coalesce in the upper part of the lungs, before 
they appear lower down, we have very often these indi- 
cations early in the disease. 

If there be no indication of more general Bronchitis, 
or Asthma, or Pleurisy, we have the more reason, in 
such cases, to suspect the beginning of Phthisis. In 
some instances, after these first indications of Phthisis, 
there is an accession of more urgent dyspnoea, but with 
feeble pulse, and found to be peculiarly intractable ; the 
symptoms take the form of Peripneumony, with less 
strength of pulse and heat of skin than usual, and last- 
ing longer, — the patient dies asphyxiated, — and on dis- 



286 OUTLINES OF PATHOLOGY AND PRACTICE. 



section it appears either that Peripneumony has super- 
vened on tubercles, or that an unusually great and uni- 
form deposit of fresh tubercles has recurred, all of them 
appearing small and translucent, i. e. in their earliest 
stage (miliary tubercles). 

More generally, the dyspnoea is less urgent, but the 
fever takes gradually the form of decided hectic, with 
night sweats, copious expectoration, partly puriform, 
often partly bloody, and partly consisting of fragments 
of tubercles, or even of earthy concretions (the remains 
of old tubercular deposits). We then expect to find 
the indications of ulceration, chiefly in the upper part of 
the lungs, — in the peculiar sound of respiration, the re- 
sonance of the voice, and especially the peculiar gurg- 
ling or clattering rale (gargouillement or rale caverneux) 
heard especially in the inspiration immediately succeed- 
ing a cough. This takes the place of the previous sub- 
crepitous rale, and informs us, with almost absolute . cer- 
tainty, that an ulcerated cavity exists at the part. 

The ulterior efl'ects or attendants of Hectic Fever on 
the mucous membrane of the alimentary canal likewise 
shew themselves before the patient is exhausted, — the 
florid tongue, the slightly inflamed, often aphthous 
fauces, the diarrhoea, known by experience to be con- 
nected (at least when it has lasted some time) with tu- 
bercular deposition and ulceration in the mucous mem- 
brane of the bowels, and usually also with swelling and 
tubercular degeneration of some of the mesenteric glands. 

In some instances, the ulceration of the lungs leads to 
perforation, and escape of air and of purulent matter 
into the sac of the Pleura, suddenly exciting the symp- 
toms of Pleurisy, on which those of Empyema and Pneu- 
mo- Thorax supervene, — the difficulty of lying, usually 



INFLAIVOIATIOISS OF THE AIR-PASSAGES, &;C. 287 

on the opposite side, — tlie unusual resonance on percus- 
sion in the greater part of that side of the chest, with 
duhiess at a smaller part of it, and absence of the respi- 
ratory murmur in both^ — the metallic tinkling heard in 
that side on breathing or coughing, — and the sound of 
jiuctuation on succussion of the thorax, — all implying the 
presence, in the sac - of the pleura on that side, both of 
air and liquid, usually purulent matter. 

In a few instances, likewise, perforation succeeds the 
ulceration in some part of the alimentary canal, causing 
the symptoms of sudden and rapidly fatal Peritonitis (of 
which afterwards) to supervene on those of the colliqua- 
tive Diarrhoea of Phthisis. 

The duration of this progress is exceedingly various ; in 
some instances, chiefly in children but likewise in adults, 
it may be gone through in a few weeks ; in others, the 
symptoms, repeatedly abating and recurring, occupy se- 
veral years. The disease may occur and even originate 
at all ages, but is somewhat more frequent, and the 
hectic fever attending it is best marked, between the 
ages of 18 and 35. 

In some instances it is certain, that after the deposi- 
tion of tubercles at the summit of the lungs has taken 
place, and some of them have coalesced and acquired 
some size, they become inert, and gradually harden into 
irregular earthy masses, no fresh deposition following. 
In a still smaller number of cases, it appears that ulcers 
already formed by the suppuration of tubercles, dege- 
nerate into fistulous sinuses connected with the bronchise, 
and do not extend. The almost universal fatality of 
the disease depends, not on the necessarily permanent 
or malignant character of ulcers of this description, but 
only on the fact, that tubercles, once deposited at this 



288 OUTLINES OF PATHOLOGY AND PRACTICE. 



part, are followed, almost universally, by successive fresh 
deposits in the middle and lower lobes of the lungs, 
which are to run the same course, to disqualify great 
part of the lungs for their office, and to be attended 
with such an exhausting process of Hectic Fever, as 
generally wears down the patient, and causes death by 
Asthenia rather than Asphyxia. 

On dissection, it most generally appears that nearly 
three-fourths of the two lungs have become disorganized 
by tubercular deposits, by ulceration, and by hepatiza- 
tion. The ulcerations are chiefly at the upper part, the 
most recent — often still translucent, — tubercles at the 
lowest; and the condensation is partly by clusters of 
tubercles, partly by tubercular infiltration, partly by he- 
patization, the two last often hardly distinguishable. 
Such an extent of lung could not have been rendered 
useless without violent dyspnoea, but for two circum- 
stances, which demand attention : — 1 . That the whole 
quantity of blood has been gi'adually much lessened ; 
and, 2. That the blood entering the lungs has gradually 
deserted the diseased portions. It is usually found, also, 
that the Pleura pulmonalis and costalis, at the most af- 
fected parts of the lungs, are adherent by lymph, with or 
without tubercular deposits in it ; that the liver is some- 
what enlarged, granular or more frequently fatty ; and 
more or less of the mucous membrane of the intestines 
(chiefly of the Ileum) affected in the ways above noticed. 
In many cases, especially in children^ the portions of 
the bronchial and mesenteric glands corresponding to 
the diseased lungs and bowels are likewise tuberculated. 

When this course of symptoms has begun, and the 
existence of condensation at the upper part of one or 
both lungs is ascertained, the case is to be regarded as 

3 



INFLAMMATIONS OF THE AIE PASSAGES, &C. 289 



an object of palliative practice only ; although^ in the 
earliest stage, a hope maybe entertained that, under 
practice hardly entitled to any other name than pallia- 
tive, the farther deposition of tubercles may in a few 
cases be stopped, those already existing pass into an 
inert state, and the subsequent progress be arrested. 

The most important measure that can be advised^ in 
cases of threatened, suspected, or incipient Phthisis, is 
a change of climate; either the South of Europe, or Ma- 
deira, or strict confinement within doors, in an artificial 
climate, as near as possible to 60° of Fahrenheit, during 
at least six months of the year, in Britain. The ad- 
vantage of the former plan is in the gentle exercise and 
mental excitement which may be secured by it, without 
risk of aggravation of the disease by cold. The inha- 
lation of the vapour of tar, in the earlier stages, and of 
the chlorine gas, very much diluted, in the latter, seems 
in some instances useful. The other means of pal- 
liative treatment best recommended by experience, and 
by the careful use of which we may hope to see the pro- 
gress of the disease retarded, the symptoms mitigated, 
and the ultimate exhaustion of the patient take place 
without intense suffering,— are the following. 

1. Repeated but cautious use of the antiphlogistic 
remedies^ small bleedings, purgatives, blisters, and other 
counter irritants, when the symptoms indicate attacks 
of " intercurrent inflammation." 

2. Some of the expectorant remedies, mentioned 
under the head of Bronchitis. 

3. Anodynes, especially opiates, in doses very gra- 
dually increased. 

4. Bitters and Astringents, particularly the Mineral 

T 



290 OUTLINES OF PATHOLOGY AND PRACTICE. 

Acids, the Acetate of Lead, and the vegetable astrin- 
gents, to check the sweatings or the diarrhoea. 

5. Constant warm clothing, and care to avoid cold or 
wet, and all exertions that hurrj the breathing; but 
gentle exercise, when the strength permits, and the 
weather is mild and dry. 

6. A diet, consisting of the lightest kinds of animal 
food, and the most nutritious (chiefly farinaceous) 
kinds of vegetable food ; the proportion of the former 
varied from time to time, and a gradually increasing 
allowance of fermented liquor given, as the disease ad- 
vances, and when the intercurrent inflammations abate. 

Sect. VI. — Of Pleurisy^ Acute and Chronic. 

The inflammation of the Pleura (in which the costal 
and pulmonic are very generally both involved) very 
often goes along with that of the subjacent portions of 
lung, but there are some cases of acute but partial, and 
many of more chronic Pleurisy, in which the substance 
of the lung appears, on subsequent examination, never 
to have been inflamed ; and if condensed, to have been 
so only by supernatant effusion {i, e. as Laennec ex- 
pressed it, to have been caruified^ not hepatized.) 

The symptoms of acute Pleurisy are simple, and nearly 
unequivocal. Fever, usually pretty high. Pain of side 
acute, and increased by inspiration, hardly either by 
pressure or motion, more or less of Dyspnoea, and within 
a day or two from the commencement of the pain, dul- 
ness on percussion at the affected part, faintness, and 
very soon suppression of the respiratory murmur at that 



5 



INFLAMMATIONS OF THE AIR PASSAGES, &C. 291 



part, and obviously impeded expansion of the chest on 
that side,* — these symptoms depending on effusion of 
serum, or liquor sanguinis, with deposition of patches 
of false membrane, and flakes of lymph, on the serou^ 
membrane ; which, after a time, extremely various in 
different cases, often passes into the form of pus. By 
these the case is in general easily distinguished from the 
Pleurodyne, or rheumatic stitch, and from thoracic Neu- 
ralgia. 

When this effusion is unusually great, it causes dis- 
tension of the whole side, and filling up of the inter- 
costal spaces, most easily perceived when the thorax is 
examined from behind; and obviously displaces the heart. 

Such large effusion is sometimes the result of acute 
Pleurisy, but more frequently of a subacute or more 
chronic form of the disease, in which the fever is slight, 
the pain little complained of, and the breathing, during 
the earlier stages, little affected, except on exertion. 

In these cases, the lung of the affected side is often 
reduced to a small bulk, and pressed against the ver- 
tebree, without being irretrievably condensed. The pa- 
tient generally, but not uniformly, lies on the affected 
side. 

The fluid effusion sometimes occupies the whole side 
of the chest, but sometimes it is confined by the effusion 
of solid lymph to portions, generally to the lower por- 

* The CEsophony, or peculiar kind of resonance of the voice, 
distinguished by succeeding, by a short interval, to the sound as heard 
from the mouth, and by the altered, somewhat shrill and tremulous 
tone, is heard probably in no other case, than when a thin layer of 
serum intervenes between the ear and lung ; but its occurrence and 
continuance are extremely uncertain ; and the friction sound, heard 
occasionally when there is effusion of concrete lymph, is also of un-^ 
certain occurrence and duration. 



292 OUTLINES OF PATHOLOGY AND PBACTICE. 



tion of it. The pressure of the effused fluid on the lung 
of the affected side, causes such condensation of it, as 
very often to produce resonance of voice (Bronchophony) 
in the upper part of that side, which renders the symp- 
toms somewhat ambiguous. 

When the effusion has become great, especially, as we 
may suppose, when it is becoming purulent, the fever 
usually takes the form of Hectic, particularly in young 
persons. 

This case of Empyema consequent on Pleurisy, with- 
out previous ulceration of the lung, is easily distinguish- 
ed from the Empyema and Pneumothorax, consequent 
on a perforating ulcer, by the dulness extending over 
the whole side ; and by there being no metallic tinkling, 
and no sound of fluctuation. 

The symptoms of the acute Pleurisy are in general 
easily relieved by early bleeding, and other antiphlogistic 
remedies ; but the local bleeding is here of greater im- 
portance, as auxiliary to the general, than in the Peri- 
pneumony. After the most urgent symptoms are re- 
lieved, the effusion may continue, and extend for a little ; 
but in this case the spontaneous cure, by its absorption, 
may be confidently expected, and sometimes takes place 
in a few weeks, or even days. 

But if the disease, although acute, has been neglected 
m the beginning, or if it has made progress in a chronic 
and insidious form, until the side has been somewhat 
distended, it may be found to shew very little tendency 
to absorption for months or years, and often becomes 
dangerous by gradual exhaustion of the strength, with 
hectic fever. In such cases, the effused lymph on the 
Pleura, in the end, generally ulcerates ; the ulceration 
may extend inwards to the cells of the lungs, and the 
matter effused, and now become purulent, may make its 



INFLAMMATIONS OF THE AIR PASSAGES, &C. 293 

way inwardly to the bronchiee, its expulsion by which 
has been often mistaken for the bursting of a vomica 
in the lungs ; or it may extend outwards^ through the 
Pleura costalis, to the cellular substance between the in- 
tercostal muscles, and under the integuments, where it 
forms an abscess, which may be opened, and by which 
the fluid within the chest may gradually be drained off. 

It is obvious, therefore, that even when a large pleu- 
ritic effusion exists on one side of the chest, there are 
still two modes by which a spontaneous cure may be 
effected, — by gradual absorption of the effusion, or by 
its discharge externally, or through the lungs. 

The operation of Paracentesis in such cases necessarily 
implies the admission of air into a cavity lined by a se- 
rous membrane, the protection of which by effused lymph 
is never certain ; and it has been so seldom followed by 
recovery, that when there is no immediate threatening 
of death by asphyxia, the chance of spontaneous cure, in 
one or other of the ways now stated, under a careful 
regimen, is certainly better than that of recovery after 
the operation. It is only, therefore, in cases of such 
urgency, that this operation can be advised. 

When it is not performed, the object of practice is to 
accelerate the absorption of the fluid efinsed, and watch 
for its accidental discharge in the ways above stated. 
Rest, confinement, and a low diet for some weeks, are 
always advisable ; and it has often been thought, that, by 
blistering, by moderate purging, by a mild mercurial 
course, by the use of digitalis and other diuretics, and 
of preparations of Iodine, the absorption was accelerated ; 
but all these have frequently been used without any ob- 
vious effect, even in cases where the absorption after- 
wards went on spontaneously and satisfactorily ; and 



294 



OUTLINES OF PATHOLOGY AND PRACTICE. 



therefore they should not be urged to the injury of the 
general health. 

After a time, in such cases, the Tonic regimen becomes 
advisable, and recovery has obviously been accelerated 
by a somewhat fuller diet, a change of scene, and gentle 
exercise. 

In whatever way the discharge of the effused fluid 
from the sac of the pleura takes place, it is followed by 
more or less of contraction of that side of the chest,-—* 
sometimes permanent, sometimes subsequently abating, 
according to the degree of injury which has been done 
to the lung, and the quantity of lymph thrown out on 
its surface. 

There are undoubtedly cases of Pleurisy, of peculiar 
fatality, and little influenced by treatment, which depend, 
as has been already stated in regard to peripneumony, on 
the presence of Suppuration in other parts of the body, 
and of purulent matter in the circulating blood. There 
are similar cases also, seen distinctly in connection with 
epidemic Erysipelas : in both these the efl'usion is puri- 
form, probably from the commencement ; and there are 
cases, seen chiefly in hospitals, in convalescents from fe- 
brile diseases, and especially from small-pox, which 
would seem to be of the same specific and peculiarly in- 
tractable character. 



( 295 ) 



CHAPTER III. 

OF INFLAMMATIONS OF THE HEART AND BLOODVESSELS. 

The diagnosis of these inflammations, formerly very 
little understood, has been much studied of late years ; 
and we have now little difficulty in recognising, in a great 
majority of cases, the existence of inflammation in these 
parts ; but we cannot place such reliance on the dia- 
gnostic marks of the Pericarditis and Endocarditis, in 
their early stage, as to entitle us to treat of them sepa- 
rately ; we know likewise, that they are often com- 
bined; and the pure Carditis, or inflammation of the mus- 
cular substance of the heart, probably never exists without 
one or other of them. It seems best, therefore, to treat 
of these inflammations together, first stating the symp- 
toms which inform us that inflammation exists within 
the pericardium, and afterwards attending to the difl'er- 
ent effects of inflammation on the external and internal 
surfaces of the heart, and the marks by which, in the 
progress of the disease, the affections of these different 
parts may very frequently be distinguished. 

The inflammations of the heart commence sometimes 
in a very acute form, with the usual symptoms of in- 
flammatory fever ; sometimes in a chronic and insidious 
form, — sometimes alone, very often combined either with 
other inflammations within the chest, or with Rheuma- 



296 OUTLINES OF PATHOLOGY AND PRACTICE. 



tism. The symptoms which may be said to be most 
characteristic are the following : — 

1. Increased pulsation at the heart, felt by the patient, 
or obvious to the band of the bystander, or both, — 
sometimes remarkably increased even by slight motion, 
probably always by exertion,— often causing a somewhat 
irregular or what has been called tumultuous heaving, 
— usually aggravated, and causing sudden starting when 
the patient is dropping asleep. With this, the pulse 
may be regular or irregular. 

2. Pain in the situation of the heart, or in the left 
side of the chest, sometimes acute, often slight, almost 
always attended with tenderness at the epigastrium. 

3. Dulness on percussion to the left of the sternum, 
(These two last symptoms are chiefly seen in the peri- 
carditis.) 

4. Dyspnoea, the respirations at first short and hur^^ 
ried rather than laboured ; often attended with peculiar 
anxiety, generally aggravated even by slight motion, 
frequently in the advanced stages relieved only by sitting 
up or leaning forwards. 

In some cases there is much cough, in some much 
vomiting, in some early delirium ; but none of these are 
characteristic symptoms. 

5. The sounds of the heart's action (in most, not all 
cases) variously altered, sometimes much fainter than 
natural ; sometimes attended with unnatural sounds, 
of which one, the rubbing sound, or bruit de frotte- 
ment, seems more general over the heart and nearer 
"the ear, and denotes effusion into the pericardium,— 
another, the bellows sound, or bruit de soufflet, often 
more limited in extent and apparently deeper seated, 
denotes the Endocarditis, and diseased state, gene- 



INFLAMMATIONS OF THE HEART, &C. 



297 



rally of the aortic valves. When these valves are dis- 
eased, the morbid sound may attend either of the natu- 
ral sounds of the heart, as is easily understood from 
what is known of the cause of the sounds. When the 
mitral valve is diseased, if there be an unnatural sound, 
it will generally accompany the second natural sound, 
and be heard most distinctly over the ventricle. 

6. In the latter case (of Endocarditis) the symptoms 
are soon found to vary remarkably, as the aortic or 
mitral valves are chiefly affected. In the former case, 
the pulse at the wrist is morbidly full and strong, and 
generally regular, or nearly so ; and the aorta usually 
partaking of the disease, the pulsation in the subclavian 
arteries is soon found to be apparently much stronger 
than natural ; in the latter case the pulse at the wrist is 
irregular, and neither corresponding in strength nor ge- 
nerally in number with the pulsations felt at the chest 
(some of the pulsations of the left ventricle causing only 
regurgitation into the auricle.) 

7. In most cases, after some weeks, in some cases 
certainly within fourteen days from the attack of the 
disease, the heart has become enlarged, and its apex is 
felt below the sixth rib. 

Of these symptoms the four first are practically the 
most important, as being earliest perceived, and some- 
times denoting a stage of inflammation which admits of 
complete resolution. When these last some days with- 
out the others supervening, the case is probably the 
Pericarditis. The three last are more pathognomonic, 
but depend on changes which are in most cases irretriev- 
able ; and when observed, are almost always present for 
a long time, often for life. 

The diseases which are most apt to become complir 



298 OUTLINES OF PATHOLOGY AND PRACTICE. 



cated, either with the Pericarditis or the Endocarditis, 
soon after their attack, are Pneumonia or Bronchitis, 
and enlargement of the Liver ; and Anasarca, with scanty 
urine, is a very frequent consequence of either combina- 
tion. 

When the case is Pericarditis only, there are material 
differences in the nature of the effusion into the sac of 
the Pericardium. In some cases it is chiefly fluid, and 
becomes partly, or almost entirely, purulent ; and in 
these the strong pulsation at the sternum generally 
abates, and the pulse becomes more irregular ; in 
others it is chiefly solid lymph, and in them the pul- 
sation at the sternum and pulse at the wrist often con- 
tinue long of morbid strength. 

This last is the almost uniform result of Rheumatic 
inflammation of the heart, which occurs very frequently, 
sometimes as a metastasis of rheumatic inflammation 
receding from the limbs, sometimes as a translation of 
rheumatism, which continues to affect difl'erent parts of 
the limbs in succession. In the latter case, the affection 
of the heart is usually more gradual and insidious. The 
great efl'usion of solid lymph in such cases is apparently 
the effect of increased proportion of Fibrin in the blood. 

The lymph that is thrown out on the Pericardium as- 
sumes generally a reticulated or fibrous aspect, and often 
quickly becomes organized, and forms permanent adhe- 
sions, — admitting, however, of very great diminution by 
subsequent absorption. 

The inflamm^ation of the inner membrane of the heart 
leads to deposition of patches of lymph on the inner 
surface both of the ventricles (chiefly the left) and of the 
aorta, and to shortening and thickening of the valves ; and 
it is one mode — we do not say the only mode- — in which 



INFLAMMATIONS OF THE HEART, kc. 



299 



otlier organic changes, as described by Andral,* are 
gradually effected in the heart and aorta. This inflam- 
mation is probably more frequently of the chronic form 
than the other, and is certainly very often overlooked or 
neglected until its effects are irremediable. It often 
occurs also as an effect of Rheumatism, and sometimes 
at the same time as the Pericarditis. 

These inflammations, and consequent lesions, at the 
heart and in the aorta, lay the foundation of many other 
diseases, — of various kinds of Aneurisms ; of Apoplexy, 
Palsy, or Epilepsy ; of Chronic Bronchitis and Asthma, 
Pneumonia, and Apoplexy of the Lungs; of Chronic 
Inflammation and Cirrhosis of the Liver, and of all 

* 1. ** A great number of the contractions of the different orifices 
of the heart take their rise from an inflammation, acute or chronic, 
of the membrane lining the cavities of that organ. 

2. " This inflammation is the first cause of many enlargements 
of the heart. 

3. "A great number of the cartilaginous and bony deposits in 
the aorta, many of the alterations which its middle coat undergoes, 
either in texture or properties, are the result of an inflammation of 
this artery. 

4. " These different organic alterations of the aorta have a great 
share in the production of enlargements of the heart. 

" We beg the reader not to extend our opinion beyond the limits 
within which we circumscribe it. We have not said that all ossifi- 
cations of the internal membrane of the heart and arteries proceed 
from an inflammatory action ; we believe that in old age the pro- 
cess of nutrition, in many fibrous or cartilaginous tissues, is modified 
in such a manner, that, without any morbid congestion of blood, these 
tissues become hard and ossified." — (Andral, Clin. Med. t. iii. p. 
468.) In like manner, we can have no doubt that other constitu- 
tional derangements, besides that proceeding from age, may so mo- 
dify the condition of these textures, as to determine the appearance 
either of bone, or of other morbid deposits, either as a result of in- 
flammation (particularly of chronic inflammation), or as a simple 
" perversion of nutrition," without previous inflammation. 



300 OUTLINES OF PATHOLOGY AND PRACTICE. 



forms of Dropsy ; but they are only to be regarded as 
the great predisposing cause of all these ; and exciting 
causes, which may be avoided, are very often concerned in 
producing or renewing these diseases in persons thus 
predisposed. The Hypertrophy of the Heart, chiefly of 
the left ventricle, seen so frequently in connection with 
the lesions now mentioned, is not to be regarded as a 
diseased state in itself, but as the consequence of these 
lesions ; and as the provision of nature for carrying on 
the circulation effectually, notwithstanding the obstruc- 
tions which they oppose, in different ways, to the flow 
of blood, chiefly through the left side of the heart and 
great vessels. 

The danger attending these inflammations is often 
imminent, and is indicated by the degree of dyspnoea and 
anxiety, produced partly by the impeded state of the 
heart's action, partly by the concomitant affection of the 
lungs ; and it is to be remembered, that, under the irri- 
tation produced by the inflammation on the membranes 
lining them, the muscular fibres of the heart are excited 
to a fallacious apparent strength of action, even when 
really enfeebled, either by evacuations, or, in . a few 
cases, by extension of the inflammation to themselves, 
causing softening of their texture ; and therefore that 
death may ensue from sudden and unexpected sinking. 
And when the disease has passed into its chronic form, 
the dano'er resultino- from its various effects and com- 
plications is always attended with another, nearly pecu- 
liar to diseases of the heart, viz. that by sudden Syncope. 

In the acute disease the antiphlogistic remedies are 
clearly demanded, and often partially successful, al- 
though the subsequent symptoms generally shew that 
some portion of the inflammatory exudation remains, 



INFLAMMATIONS OF THE HEART, &C. 



301 



impeding more or less tlie free action of the heart, and 
flow of the blood. But the fact just stated enables us to 
understand, that large and repeated general bloodletting, 
particularly in the case of Pericarditis, when there is 
pressure from the effused fluid on the external surface 
of the heart, may irretrievably depress its actions, and 
aggravate the danger. Accordingly, it may be stated 
with confidence as the result of experience, that repeated 
(often many times repeated) local bloodlettings are more 
efl'ectual than much general bleeding, in arresting the 
immediate danger, and probably diminishing the ulterior 
bad eff*ects, of this inflammation. And this applies par- 
ticularly to the case of Rheumatic Inflammation of the 
Heart, where the chance of subsequent translation or 
extension of the disease to the extremities seems to be 
much diminished by large and weakening loss of blood. 

The danger of the acute form of the disease may be, 
in some measure, obviated likewise by strict antiphlogis- 
tic regimen, and by other antiphlogistic remedies ; parti- 
cularly by blistering, by purgatives and diaphoretics ; in 
some cases by sedatives, such as Antimonials or Digi- 
talis ; and perhaps to a certain degree by Mercury, given 
(usually in the form of Calomel and Opium) so as to 
afi'ect the mouth, in the hope that it may control the 
deposition, or promote the reabsorption, of lymph. But 
experience does not entitle us to place much reliance on 
this last expedient. 

When the affection of the heart has passed into the 
more chronic form, or when, from peculiarity, and espe- 
cially from debility of constitution, it has been always 
somewhat latent, we know from examination of fatal 
cases, that it may be attended with much general de- 
pression of vital action, more or less resembling typhoid 



302 OUTLINES OF PATHOLOGY AND PEACTICE. 



fever, while the symptoms at tlie heart itself are slight ; 
and in cases of this kind wine and other stimulants 
may be cautiously given with good effect. 

When the enlargement, and generally the hyper- 
trophy of the heart, are obvious, and the obstruction to 
the flow of blood through it is indicated by palpitation 
and dyspnoea on exertion, by the morbidly strong or 
peculiarly irregular pulse above noticed, by starting 
from sleep (erroneously attributed by Cullen to Hydro- 
thorax), often by difficulty of lying down, and usually 
by more or less of the morbid sounds attending the 
heart's action, — the permanent drain of an issue or 
seton has sometimes appeared useful; the effect of a 
continued course of mercury or iodine as an alterative 
may be tried, and in some cases the frequent use of 
Digitalis, or of Hydrocyanic acid^ has seemed to calm 
the excited action : but the main object of practice in 
such cases is, to preserve the patient, by a careful re- 
gimen, from the exciting causes by which any of the 
ulterior consequences above stated may be determined ; 
and when any of them shall appear, by appropriate 
evacuations, to which moderate but early bloodletting 
will generally be the most important preliminary, to 
moderate their attacks, and dispose them to a favourable 
termination. 

The same diseased states, often resulting from chronic 
inflammation of the arteries, which, existing in the 
neighbourhood of the heart, produce the results now 
considered, frequently exist in the larger arteries of in- 
dividual parts of the body, where they become known 
only by the non-febrile diseases to which they ultimately 
ie^d, of which the most important are, in the head, 



INFLAMMATIONS OF THE HEART, &C. 303 

Apoplexy and Palsy, or various alterations of tlie func- 
tions of tlie Brain and organs of Sense, sometimes re- 
sulting suddenly from rupture of vessels ; sometimes 
more gradually from a disordered state of the circula- 
tion ; and in tlie extremities, Gangrene, wliich some- 
times results rapidly either from rupture of the internal 
coat of an artery (previously in a state of softening, 
probably the result of a peculiar inflammation), and ob- 
struction of the course of that blood in it, or in a few- 
cases from inflammation, attended with acute pain, and 
going rapidly to effusion and obstruction ; in other cases 
this supervenes slowly on the morbid state of the circula- 
tion consequent on the diseased and inert condition of the 
arteries ; perhaps rather on inflammation, very easily 
excited, and tending always to this termination, in parts 
where the circulation is so affected ; and in both cases, 
when it has shewn itself, appears to admit of no other 
treatment than moderating the constitutional affection 
that is excited, and which is considerably various, some- 
times inflammatory fever — sometimes distinctly typhoid 
- — sometimes very slight, but long continued — often at- 
tended with much pain and restlessness, and remarkably 
benefited by frequent opiates ; and promoting by gentle 
means the separation, sometimes effected by nature, of 
the mortified from the sound parts of such limbs. 

Inflammation of the Veins is of more frequent occur- 
rence, often resulting from injuries of different kinds, 
and perhaps, more frequently than is commonly sup- 
posed, originating spontaneously. It may often be known 
by the swelling, ha^rdness, and tenderness of the vein, if 
within reach of the finger ; but in many cases is attend- 
ed with so much swelling of neighbouring parts, either 



SOi OUTLINES OF PATHOLOGY AND PRACTICE. 



erythematic or anasarcous, as to be detected with diffi- 
culty. Hence it is often known, or suspected, chiefly 
from its effects. It causes rapid thickening of the coats 
of the vein, and inflammatory efi'usion into its interior, 
sometimes of lymph only, sometimes of pus ; and the 
great diff'erence of the progress of the disease, in difi'erent 
cases, seems to depend chiefly on the nature of this ef- 
fusion. 

It is certain that in some cases of Venous inflamma- 
tion there is comparatively little either of constitutional 
disturbance or of danger ; and that evacuations, at least 
repeated local bleedings, are well borne and obviously 
useful. In such cases, the chief result observed from it 
is painful oedema, or rather elastic swelling (dependent 
apparently on eff'usion of liquor sanguinis, not of serum 
only), in the parts beneath the aft'ected portion of vein ; 
and of this the most familiar examples are the Phleg- 
masia dolens of women after delivery, and the swelled 
leg occasionally seen after fever ; but the same painful 
swelling of limbs occjirs in various other cases, particu- 
larly in the lower limbs, in connection with various dis- 
eases of the Pelvis, or of the Groin, or idiopathically ; 
and is benefited by the local bleeding, which is well 
borne, and may sometimes be carried to a great extent. 
In some such cases it has been ascertained, and in all such 
it is very probable that the eff'ect of the inflammation is 
effusion of coagulable lymph only, obstructing the vein. 
There are some cases of this character which are followed 
by rapid inflammation of internal parts, likewise admit- 
ting of efl'ectual relief from antiphlogistic treatment. 

But in other cases, inflammation, even of a smaller 
vein, as that succeeding bloodletting, becomes imme- 
diately attended with extreme danger, of the kind for-^ 

3 



INFLAMMATIONS OF THE HEART, &C. 



305 



merly noticed, being followed by vomiting and purging 
in many cases, and by typhoid fever and rapid sinking ; 
with or without another series of consequences, in them- 
selves attended with much danger, viz. the secondary 
inflammation, and rapid purulent deposition, either in 
internal parts, — the lungs, the pleura, the liver, kidneys, 
even the eye, the brain, or heart, — or else in some of 
the joints. In such cases it is generally found, on dis- 
section, that there is little or no effusion of lymph lining 
the inner membrane of the vein, but a little purulent 
matter is found in it ; and from the history above given, 
there can be no reasonable doubt, that purulent matter 
formed in the vein, circulating in the blood, and acting 
as a poison, is the cause of the typhoid fever and of the 
secondary inflammations. 

Such cases are often found in connection with ery- 
thematic or diffuse inflammation of the skin and cel- 
lular substance ; and there can be little doubt that many 
such, at least, are cases of specific inflammation of the 
Veins^ — tending here, as in other parts, to fluid puriform 
effusions, rather than to exudation of plastic lymph. 

These last cases admit of the antiphlogistic treatment 
only in their commencement ; in their later stages the 
remedies for typhoid fever are demanded, but the chance 
of success from them is extremely small. But in the 
former class of cases, the repeated local bleeding, fomen- 
tations of the affected limbs, absolute rest in the recum- 
bent position, and the general antiphlogistic treatment, 
at first, followed by blistering over the affected part, and 
gentle frictions, and the cautious use of Mercury and of 
Iodine, are often successful. Partial venous obstruction, 
however, very generally remains ; and oedematous swell- 

u 



306 OUTLINES OF PATHOLOGY AND PRACTICE. 



ing and ulcers of the limb are easily produced by exer- 
tion. The use of a bandage or laced stocking is often 
found beneficial ; but caution is necessary as to thus 
forcing the blood against the obstructed portion of the 
vein, as long as inflammation still exists, or is easily re- 
excited in it. 



( 307 ) 



CHAPTER IV. 

OF INFLAMMATIONS OF THE VISCERA OF THE ABDOMEN 
AND PELVIS. 

Some of the diseases depending on inflammations of 
these parts may be confidently distinguished, but several 
of them are frequently combined, and the distinctions 
most satisfactorily observed are somewhat different from 
those which have been most generally described by 
authors. 

Sect. I. — Of Hepatitis^ or Inflammation oj 
the Liver, 

This disease occurs occasionally in the acute form, 
perhaps more frequently in the chronic form. In both 
forms it is more frequent in the warmer climates than 
with us. In both it may tend to suppuration ; and of 
the more chronic form there is a very frequent termi- 
nation in enlargement and induration, from which vari- 
ous important results may follow. 

Cases corresponding in all respects to Dr CuUen's 
definition of the Hepatitis acuta, with high fever, pain- 
ful swelling of the right hypochondrium, resembling 
pleurisy, increased by lying on the left side, pain of 
right shoulder, dyspnoea, dry cough, vomiting, and 



308 OUTLINES OF PATHOLOGY AND PRACTICE. 



hiccup, are not common ; tliey depend on inflammation 
peculiarly affecting the peritoneal surface of the Liver \ 
or Diaphragm, and are sometimes hardly to be distin- 
guished from inflammation of the lower part of the 
pleura of the right side ; particularly as it sometimes 
happens that the inflamed liver does not project lower 
than usual in the hypochondrium, but extends upwards 
and encroaches on the cavity of the chest. Such cases 
are no donbt often successfully treated without the real 
seat of the inflammation being ascertained. The dia- 
gnosis of Hepatitis is the more difficult, as in many cases 
the flow of bile is not obviously changed from its natural 
state. But in most cases some of the symptoms above 
mentioned exist, and cause at lea.st strong suspicion of 
the disease, both when in its acute and chronic form. 

In some cases there is temporary jaundice with in- 
flammation of the Liver, pointing out the seat of the 
disease when the pain in the side is little felt, but not 
necessarily indicating that the inflammation has been 
originally seated in the Liver, because the same symp- 
toms may result from swelling of the Pancreas or other 
adjoining viscera (even the kidney) pressing on the bile- 
ducts ; in some the hypochondrium is felt to be full, 
tender, and dull on percussion, although there is little 
complaint of pain ; and it is important to remember, that 
in many cases in the warmer climates, and some in this 
climate, there is Diarrhoea or Dysentery in connexion 
with inflamed Liver. 

It is important to remember also, that inflammation 
of the Liver, going to suppuration, is a common conse- 
quence of severe bodily injuries, especially, as has been 
repeatedly stated, of injuries of the head, even when 
there has been no obvious concussion of the whole body ; 



INFLAMMATIONS OF THE VISCERA, &C. 



309 



— and again, tliat the Liver is one of the organs in 
which secondary inflammations, going on rapidly to sup- 
puration, have often occurred in connexion either with 
inflamed viscera, or with the removal of a large suppu- 
rating surface, and the presence, therefore, of purulent 
matter in the blood. 

When inflammation of the Liver, whether attended 
by well marked symptoms or more latent, is going on to 
suppuration, the fever often takes the form of hectic ; 
but in the more chronic cases, when a number of small 
abscesses are formed in the Liver, the hectic is often not 
observed, and the fever in the advanced stages takes the 
typhoid form. 

There are many cases in which swelling and tender- 
ness of the Liver, with some degree of fever, are obvi- 
ous, which never tend to any other termination than 
chronic enlargement and induration of the Liver, with 
the formation of distinct tubercles, of different kinds, in 
some cases, and of granular degeneration, or Cirrhosis, 
in others. But there are other cases of still slower pro- 
gress, in which these lesions of the Liver take place 
without any inflammatory symptoms ever shewing them- 
selves. In such cases there are often various dyspeptic 
symptoms attending the disease of the liver ; sometimes 
much vomiting, in other cases none, — sometimes com- 
plete anorexia, in other cases a morbidly keen appetite ; 
often diyness of the tongue, and a very peculiar fetor of 
the breath ; and usually either a defect or a morbid 
quality of bile in the stools ; frequently there is dis- 
charge of blood by stool, — occasionally by vomiting ; 
but in some instances we can hardly point out any other 
attendants than gradually increasing debility and ema- 
ciation, usually with a sallow complexion. 



310 OUTLINES OF PATHOLOGY AND PEACTICE. 



The chronic affections of the Liver exist occasionally 
in young persons, as scrofulous affections. In persons 
more advanced in life, the tendency to these is remark- 
ably given by three causes, — by paroxysms of intermit- 
tent fever — by chronic disease of the lungs or heart, im- 
peding the passage of the venous blood through the 
chest — and by indulgence in the use of spirits. 

When inflammation of the Liver, whether in its more 
obvious or more latent form, has ended in suppuration, 
the abscess may make its way, with the aid of adhesions, 
either upwards into the cavity of the pleura, or down- 
wards into the cavity of the abdomen, or outwardly at 
the hypochondrium, or between some of the false ribs, 
or into the cells of the lungs, or into the stomach or 
intestines ; and there are many instances of recovery 
after the three last terminations, particularly after open- 
ing of the abscess which presents itself at the hypochon- 
drium or side. The inflammation excited by the effu- 
sion of pus from this source on the serous membranes of 
the thorax or abdomen is probably always rapidly fatal. 

When the acute Hepatitis is detected in its early 
stage, repeated general and local bloodletting, blistering, 
and purging, will probably often cause it to terminate by 
resolution. And this is one of the cases in which it has 
been so confidently asserted that the affection of the 
constitution by Mercury has a specific effect on the in- 
flammation, — that it is always right, miless some'peculiar 
objection to it exists, to give the patient the farther 
chance of benefit from that remedy, although it is certain 
that, in this climate, salivation has often been excited 
without apparent influence on the inflammation. 

Even in the warm climates it seems to be admitted, 
that when the disease has lasted some time and passed 



INFLAMMATIONS OF THE VISCERA, &C. 



311 



into suppuration, nothing is to be hoped from the speci- 
fic effect of Mercury. In such cases, as in others, when 
extensive suppuration has taken place, maintaining the 
strength, and relieving the feelings of the patient by 
light nourishing diet, quinine and acids, and small quan- 
tities of fermented liquors, and by opiates alternated with 
mild laxatives, must be our chief resources until the place 
of discharge of the pus shall have shewn itself. In 
many such cases, however, death takes place by gradual 
exhaustion of the strength, without any discharge of the 
pus. 

In cases of chronic enlargement of the liver, when 
the constitution seems sound, and we have reason to 
suppose that there is only congestion or chronic inflam- 
mation, or perhaps commencement of the granular de- 
generation, we may hope that a reduction of the swell- 
ing, and restoration of the more healthy condition of the 
gland, may be effected, chiefly by light diet, with little 
animal food, and no strong liquor — by mineral purging 
waters, or frequently repeated doses of any of the saline 
purgatives — ^by gentle exercise, and by a mild course of 
mercury ; perhaps we may use with more confidence a 
long-continued course of Iodine or the Hydriodates, and 
nitric acid or different preparations of Chlorine. But 
when the constitution has been previously evidently im- 
paired, or debility and emaciation are rapidly advan- 
cing, it is probable that the disease of the liver consists 
essentially in some kind of heterologous formation ; and 
in that case, as we have no reason to think that absorp- 
tion of these can be effected, more than palliative prac- 
tice ought not to be attempted. 

It is important to remember, that in the natural pro- 
gress of the most common organic disease of the liver, 



312 OUTLINES OF PATHOLOGY AXD PRACTICE. 



cirrhosis or granular degeneration, a diminution of size, 
with increasing irreguharity of surface of the gland, usually 
succeeds its first enlargement, the disease apparently 
depending essentially on granular deposits on the pro- 
longations of the capsule of Glisson throughout the 
substance of the gland, which gradually compress, and 
lead to absorption of, the glandular structure : therefore 
that reduction of a swelled liver, unless attended by de- 
cided improvement of the general health, may be quite 
fallacious. Such chronic disease of the liver is not mi- 
frequently fatal, apparently by transference of the dis- 
eased state to the head, and supervening coma ; which 
is easily understood when we perceive that Bile is retained 
in the blood, but is sometimes observed also without 
manifest symptoms of jaundice. 

Enlargements of the Spleen frequently coexist with 
those of the liver, particularly in those who have suf- 
fered from Intermittent Fevers : or exist alone, some- 
times for a great length of time. They are often con- 
nected with repeated fits of hfematemesis. In these cases, 
the most important practical observation is, that prepa- 
rations of Mercury are very apt to afiect the system 
violently and injuriously ; and that blisters, and fre- 
quently repeated laxatives, combined with bitters and 
preparations of Iron, have seemed the most useful re- 
medies. 

Change of scene and of climate are so frequently use- 
ful in such chronic affections, both of the Liver and 
Spleen, as to afi'ord sufficient evidence that an effectual 
tonic regimen may determine the absorption of much of 
the matter V)y Avhich such diseases are constituted. 

Iuflammatir)n of thr^ Pancreas, acut'^' and chronic, 



INFLAmiATIONS OF THE VISCERA, kc. 313 



tending to nearly tlie same terminations as in tlie Liver, 
has been often observed on dissection, but seldom recog- 
nized during life witb certainty, the symptoms having 
been neither uniform nor satisfactory. Pain, deep seated 
at the epigastrium, referred more frequently to the back 
than the upper part of the abdomen, sometimes with vo- 
miting, with more or less of Fever, and without the cha- 
racteristic symptoms of other abdominal inflammations, 
may excite suspicion of this seat of the disease, but 
demands no peculiarity of practice. 



Sect. II. — Of Peritonitis, or Inflammation of the 
Peritoneum. 

This inflammation is in general easily distinguished 
from that of other textures in the abdomen, but extends 
so generally over the peritoneal surfaces, that it is to 
no purpose to make species of it according to the difi'e- 
rent organs chiefly aff'ected. It is known by general 
pain and tenderness of the abdomen, aggravated by in- 
spiration, and causing the respiration to be strictly tho- 
racic, with febrile symptoms, vomiting, often hiccup, 
and obstinately costive bowels. The pulse in general 
soon becomes small, or even weak ; but this depression 
of the circulation is unattended by the other symptoms 
of typhoid fever ; in most cases the abdomen becomes 
gradually distended with flatus in the intestines, the 
cause of which is not known, and the degree of which, 
at least in young persons, bears no fixed proportion to 
the danger of the disease. 

These symptoms are in general sufficiently cha- 
racteristic, but in women (in whom the disease is much 



314 OUTLINES OF PATHOLOGY AND PEACTICE. 



more frequent than in men), they are sometimes very 
exactly imitated, especially in irritable habits, in the 
course of painful affections which are neuralgic, not fe- 
brile nor inflammatory, and which can only be distin- 
guished from acute inflammation by careful observation 
and attention to the previous history and constitution of 
the individuals. And there are cases of inflammation 
of the spinal cord, and likewise of the kidneys, where 
the symptoms, during great part of the disease, are very 
nearly the same. 

Partial inflammations tending to suppuration (unless 
opposed by active treatment) in difterent parts imme- 
diately exterior to the Peritoneum, likewise occasionally 
cause symptoms almost exactly similar. Of such inflam- 
mations the most common seat is the cellular mem- 
brane immediately surrounding the coecum. 

The symptoms described as Peritonitis, are just simi- 
lar to those which result from strangulated hernia : and 
inquiry into the possibility of this cause for them, should 
always precede all other measures. 

The danger of the disease is denoted merely by 
failure of the circulation ; the breathing becomes hur- 
ried only in the last stage, when the blood is stagnating 
in the lungs, from feebleness of the propeUing power. 
The functions of the Brain are almost always entire to 
the last moment. 

The duration of this inflammation is extremely va- 
rious, the appearances on dissection necessarily va- 
rious likewise. The most rapid cases are generally 
those which are excited by a perforating ulcer in the 
stomach, intestines, or gall-bladder, and eftusion of their 
contents on the peritoneal surface ; in which case the in- 
flammation is sometimes fatal, by its depressing effect on 



INFLAMMATIONS OF THE VISCEEA, &C. 315 



the circulation, before any exudation has taken place on 
the membranes. In other cases, even of the acute dis- 
ease, tending merely to eflPusion of soft lymph, and of 
more or less of purulent matter, the disease may be 
prolonged for several weeks ; between these extremes 
there are numerous intermediate cases ; and the quan- 
tity of inflammatory effusion found after death, bears no 
fixed proportion to the duration of the case, nor to the 
urgency of the pain and fever. 

The occurrence of gangrene, as a consequence of this 
inflammation, is not uncommon, but in the majority of 
fatal cases, although preceded by extreme feebleness and 
coldness of the surface, there is no gangrene. 

What ought strictly to be called cases of the Chronic 
Peritonitis, are those which tend, not to effusion of pre- 
ternatural membranes, nor of purulent matter, but to 
the thickened granular state of the membrane formerly 
noticed, with which thickening and shortening of the 
Omentum, are usually combined. In a majority of 
cases of this kind, there are tubercular deposits, or other 
heterologous accretions on the membrane, and frequently 
likewise in the mesenteric glands, and perhaps in other 
textures within the abdomen ; and the connection of 
these with inflammation, — chiefly with repeated recur- 
rences of inflammation, — seems to be exactly analogous 
to the connection of tubercular disease of the lungs with 
Pneumonia, although the tubercles within the abdomen, 
probably in consequence of not being exposed to the air, 
have no such tendency to suppuration and ulceration as 
those in the lungs. In some of these cases, the tuber- 
cles remain of small size, but the adhesions which they 
form materially derange the functions of the bowels, 
causing a very irregular state of the alvine evacuations ; 



316 OUTLINES OF PATHOLOGY AND PRACTICE. 



and in some sucli cases, the muscular fibres of the intes- 
tines are found afterwards in a state of hypertrophy ; but 
in other cases, especially in children, the tubercles attain 
gradually an enormous size, causing the disease de- 
scribed by Dr Baron, without materially deranging the 
actions of the bowels, or altering the subjacent textures. 

In such chronic cases, the nature of the disease is 
generally shewn by the tenderness, enlargement, and 
hardening, and sometimes peculiarly matted feeling of 
the abdominal parietes ; the general symptoms are very 
various, but always more or less analogous to those of the 
acute Peritonitis, — -more partial, and less intense, than 
in that form, but repeatedly recurring. 

It is farther to be observed, that the acute form of 
the disease is very often complicated with previous dis- 
ease, which may have been slight, and shewn itself by no 
distinct indication, but may nevertheless be part of the 
cause of the excitement of the inflammation, and may 
be an impediment, or even an irremediable obstruction, 
to the abatement of the disease, and restoration of the 
natural action of the intestines. One frequent cause of 
this kind of complication is, adhesion from previous in- 
flammation of the bowels themselves, or of the neigh- 
bouring viscera {e. g, the omentum, the appendix vermi- 
formis, the ovaria, or ligaments of the uterus), and an- 
other is a recent intussusception from irregularly excited 
action of some part of the intestines, or a thickening and 
imperfect stricture of some part, or the pressure of an 
adjoining enlarged viscus, or morbid tumor. The possi- 
bility of acute Peritonitis being complicated with, and 
partly dependent on, some such permanent disease, as 
well as of its dependence on a perforating ulcer (which 
may have hardly caused any previous symptom) is al- 



INFLAMMATIONS OF THE VISCEEA, &C. 



317 



ways to be remembered, with a view to Prognosis and 
to Practice. 

Even independently of sucli complication, tbe acnte 
form of the disease is always to be regarded as very 
dangerous ; tbe peculiar nauseating pain, and sickness, 
unless relieved within a very few days, may produce 
fatal depression of the heart's action; and the more 
chronic form of the disease, on account of the various 
complications above noticed, is very generally ultimately 
fatal. 

Under early and active treatment, however, the acute 
form of the disease often subsides rapidly and perfectly ; 
and even when some organic lesion exists, as its con- 
comitant or consequence, if it is not one which necessa- 
rily obstructs the action of the intestine, the patient may 
be restored to tolerable health. 

The only remedy on which reliance should be placed 
is full and repeated bloodletting, general and local, — 
the latter being most important in cases of the sub-acute 
or less urgent form ; and the practical precept next in 
importance is, to refrain from the use of purgative medi- 
cines during the violence of the inflammation (which is 
often found either to excite urgent vomiting, and of 
course fail of effect, or to aggravate the pain without 
relieving the bowels), and trust the evacuation of the 
bowels ouly to enemata ; of which the most powerful are, 
that consisting of four or even six pounds of pure warm 
water, and that consisting of a scruple or half a drachm 
of tobacco leaves, infused in four or six ounces of water, 
and given every hour or two until it operate. If these 
means, after full bleeding, fail of effect, the probrtbility 
will always be very strong, that a mechanical impedi- 
ment exists to the effectual action of the bowels, which 



318 OUTLINES OF PATHOLOGY AND PRACTICE. 



cannot be removed, and may be aggravated or increased 
to internal strangulation by the use of purgative medi- 
cine. But wlien the pain and sickness have considerably 
abated, the action of a mild laxative, securing complete 
evacuation of the canal, may be very useful. 

When the patient, as often happens, does not rally 
from the peculiar depression of the disease after full 
bleeding, and the pain and sickness continue, essential 
advantage may certainly be derived from full and re- 
peated doses of Opium, which in these circumstances 
will not be found to interfere with the evacuation of the 
bowels, and will give great relief to the patient ; it is 
doubtful whether this practice can be said to have any 
directly beneficial effect on the inflammation, but it may- 
be confidently said that under it the pulse will become 
fuller and firmer, and that a greater loss of blood, if re- 
quired on account of the symptoms, will be borne with- 
out sinking, under this alternation of remedies, than if 
bleeding only is relied on. 

Along with the Opium, Calomel may be given, in the 
view of guarding against constipation, and promoting 
perspiration, and many have thought the specific effect 
of Mercury beneficial ; but it certainly ought not to be 
given in such large and repeated doses as may excite 
sudden and violent salivation, for such action of mer- 
cury has been repeatedly found to aggravate or renew the 
abdominal pain, at the same time exciting dysenteric 
symptoms, as dangerous as the original disease. 

In the height of the inflammation, no other remedies 
are to be advised. Hot fomentations and the semicu- 
pium are probably better than blisters ; but if the dis- 
ease is becoming chronic, these are probably more im- 
portant. When the most violent symptoms have abated, 



INFLAMMATIONS OF THE YISCERA, &C. 319 



there is often remitting pain, with some degree of dis- 
tension, frequent and soft pulse, and other marks of 
great debihty, for some time ; and complete recovery 
may take place under small quantities of wine, along 
with alternation of mild laxatives, enemata and opiates, 
and perhaps occasional leeching. There are even a few 
cases (particularly some recorded by Dr Abercrombie) 
in which the full use of wine and other stimulants was 
successful, after the pain had wholly subsided, and the 
patient fallen into the state of extreme debility and 
coldness usually preceding death. 

There are cases of obstinate obstruction of the bowels, 
with more or less of the symptoms of Peritonitis, but 
quite chronic, in which Mercury may be given gradually, 
and without risk of violent action ; and in some such 
cases the constipation has yielded when salivation has 
been established. 

But in cases of the chronic form of the disease, when, 
from examination of the abdomen, from the known con- 
stitution of the patient, or the degree of emaciation and 
debility, we have reason to believe that tubercular or 
other heterologous deposits exist, it is right to refrain 
from active interference, and confine the practice to the 
palliation of symptoms. 

The Peritonitis is peculiarly apt to occur within a few 
days after parturition ; and many such cases present no 
peculiarity of importance. They are usually attended 
with suppression of the lochial discharge, and with the 
usual inflammatory fever, and bear evacuations well. 
In some cases, however, it is certain that the inflamma- 
tion at this time commences at the Uterus, and never 
extends over much of the peritoneal surface, — that the 
Fallopian tubes and inner membrane of the Uterus are 

7 



320 



OUTLINES OF PATHOLOGY AND PRACTICE. 



affected in some, the substance of the Uterus in others ; 
and that, in connection with this uterine inflammation 
in some such cases, there is inflammation extending 
along the Uterine veins to the Iliac vein on one side, 
causing efi'usion of lymph in its interior, closing its area, 
and thereby producing that painful swelling of the limb 
to which the name Phlegmasia dolens has been given, 
and for which the only efl'ectual remedy is the local 
bleeding over the aff'ected vein. 

Besides these, which may be thought to be healthy 
inflammations of the difl'erent textures connected with 
the uterus at this period, it is certain that, in the con- 
tagious disease called Puerperal fever, of which many 
wasting epidemics have been recorded, there is uniform- 
ly peritoneal inflammation, beginning at the Fallopian 
tubes and ovaria, and extending over the peritona3um ; — 
that, in some cases, and in some of these epidemics, the 
inflammatory symptoms have been urgent, and the de- 
pleting remedies have been well borne, and been often 
successful ; but that the appearances on dissection in 
the fatal cases, even of these epidemics, have been pecu- 
liar in this respect, that the inflammatory efl'usion has 
been unusually fluid, purulent, or serous mixed with 
pus, or resembling soap and water, and little or no 
plastic lymph, capable of forming adhesions, has been 
efl'used. The fever, even in such case|^, often shews 
more distinctly typhoid symptoms, than in the usual 
cases of peritonitis. And in the most urgent and ra- 
pidly fatal cases of this kind, it is certain that the pain 
has very soon abated; the patient has sunk rapidly 
under all varieties of treatment ; and on dissection, in 
those most rapidly fatal cases, there has been very 
little mark of inflammation. From all these circum- 



INFLAMMATIONS OF THE VISCERA, &€. 



321 



stances we are assured, that, in tliese cases, there is a 
specific inflammation attending a contagious disease 
whicli results from a morbific poison ; and experience 
farther shews, that this may very generally be avoided, 
by avoiding all intercourse during and after labour with 
any one who has been in contact with similar cases pre- 
viously. 

It is farther ascertained, that this specijiG inflamma- 
tion, the peritoneum, is not confined to cases of this 
kind, — that it is occasionally seen in manifest connexion 
with epidemic, or frequently occurring erysipelas, or 
difi'use external inflammation, — that it may spread epi- 
demically independently of parturition, especially in 
hospitals where erysipelas has prevailed, and that the 
best marked cases of it present always similar peculiari- 
ties in their history, to those by which the worst cases 
of external erysipelatous inflammation are distinguished, 
— viz. that they are attended by much depression of the 
circulation,-— are little benefited by depleting remedies, 
—and shew, on dissection, fluid efliisions almost ex- 
clusively while it is equally certain that the same 
contagion, acting on certain constitutions, may excite, 
whether internally or externally, inflammations in all 
respects of more healthy character. 



Sect. III. — Of Injkimmation of the Mucous Membrane 
of the Stomach and Intestines, 

This inflammation presents itself in a great variety 
of forms, some of them often obscure. 

A certain degree of inflammation of the mucous 
membrane of the stomach certainly takes place in many 

X 



322 OUTLINES OF PATHOLOGY AND PRACTICE. 



cases of severe dyspepsia, — particularly, as Dr William 
Philip has shewn, in the advanced stages of dyspepsia. 
It may be relieved by bleeding, general or local, al- 
though, in many such cases, there are objections to 
large or repeated evacuations of blood, on account of the 
general habit of body. When occurring in connection 
with amenorrhoea, it is sometimes effectually relieved by 
hsematemesis ; and when not effectually opposed by 
remedies, it may go on to ulceration, and ultimately to 
perforation, without the symptoms ever having been 
urgent — the pain constant, or any well marked fever 
having been excited. 

Acute inflammation of the mucous membrane of the 
stomach, except from acrid poisons, is very rare. There 
are, however, pretty numerous cases of pain felt in the 
situation of the Cardia or of the Pylorus, at the time 
of food entering the stomach, or about two hours after, 
and attended with more or less of the regurgitation or 
vomiting of food, which improve under the use of mer- 
cury, and which probably depend on chronic inflam- 
mation, — this being, as in other cases, one mode, and 
not the only mode, in which organic disease of these 
parts may be produced. 

Inflammation of the mucous membrane of the Small 
Intestines occurs more frequently. It is the case desig- 
nated (erroneously) by Cullen as Enteritis Erythema- 
tica ; and is shewn by fever, with pain of abdomen, of 
varying intensity, with little or no tenderness, with 
much vomiting in some cases, but not uniform vomiting, 
and with a loose state of the bowels, generally with- 
out tenesmus, and without discharge either of blood or 
mucus. It is attended with much depression, with 
rapid emaciation, and frequently with tympanitic dis- 



INFLAMMATIONS OF THE VISCERA, &C. 323 



tension in its later stage. Its tendency is, first, to 
effusion of patches of lympli, sometimes pretty large 
shreds of false membrane, ^d then to ulceration, chiefly 
in the patches of mucous glands in the lower part of the 
Ileum. Such an inflammation, with more or less of 
these symptoms, occurs very often as an attendant 
of typhoid fever, and as such will be considered after- 
wards. Idiopathically it occurs occasionally, sometimes 
with so little fever or other symptoms (when the ul- 
cers found are few), that it has led to perforation in 
persons not previously thought ill. It is most frequent 
in children and young persons, and in a sub-acute form, 
and in them seems to be the cause of the best marked 
cases of Febris Infantum Hemittens ; i. e. of frequently 
occurring irregular febrile attacks, with pains of the 
head and bowels, and an irregular, but, as the disease 
advances, generally loose state of the bowels. Such at- 
tacks are sometimes effectually relieved by purging, and 
would then seem to depend on irritation, from aliments, or 
from morbid secretions, acting on the mucous membrane ; 
but when not speedily relieved in this way, they may 
always excite suspicion of this inflammation, and may 
be most frequently relieved by loss of blood, general or 
local, and by opiates in small doses, alternated with the 
mildest laxatives and antacids. 

The use of the latter medicines, in such cases, must, 
of course, be regulated partly by the appearance of 
the stools ; but the most important evils to be appre- 
hended may take place, and the most useful practice be 
employed, where there are great varieties in this respect. 

Such cases, in children, depending on more or less of 
inflammation in this membrane, are often distinguished 
with great difficulty from continued and contagious 



324 



OUTLINES OF PATHOLOGY AND PRACTICE. 



fever, wliich is usually in them of mild character, and 
of somewhat remitting type ; and they demand miimte 
attention also on account of J:heir tendency to pass into 
one or other of two very important diseases, the history 
and treatment of which will be considered afterwards — 
into Hydrocephalus, apparently by metastasis of the in- 
flammation, or into Tabes Mesenterica, by reason of a 
connexion with deposition of tubercles (both in or behind 
the mucous membrane, and in the mesenteric glands), 
just similar to the connexion, formerly considered, of 
Pneumonic inflammation with Phthisis pulmonalis. 

There is a case, not very uncommon in this country, 
of slight or transient pains of abdomen, attended with 
little fever, but with much nervous irritability, restless- 
ness, and disturbed sleep, and with the discharge from 
the bowels of long shreds of lymph, gi'ooving or marking 
the stools. Some cases of this kind probably go on to 
ulceration; but they often terminate favourably under the 
use of repeated local bleedings, blisters, the warm bath, 
diaphoretics, and opiates. When fatty concretions are 
discharged from the bowels, there is always reason to 
apprehend heterologous deposits, probably with ulcera- 
tion. 

But the case of Inflammation of the mucous mem- 
brane of the intestines most frequently demanding active 
treatment is the Dysentery, — i, febrile symptoms with 
pain, often very severe, but remitting, in the abdo- 
men, tenesmus, and frequent scanty stools, bloody and 
mucous, " retentis fa^cibus alvinis." In the most severe 
cases this is attended with vomiting, and sometimes with 
rapid sinking ; in others it passes into a more chronic 
state, the fever takes somewhat of the typhoid form, and 
when the patient has become very feeble, the peculiari- 



INFLAMMATIONS OF THE VISCERA, &C. 325 



ties of the alvine discharges abate, and the flux becomes 
simple Diarrhoea, It is known that these symptoms 
depend on Inflammation running the course formerly 
described, and ending in ulceration, sometimes in partial 
gangrene, in the mucous membrane of the great intes- 
tines. 

In some cases the disease runs its course with great 
rapidity, and is fatal by rapid sinking, in like manner 
as the Peritonitis, when the only visible effect of the in- 
flammation is effusion of lymph, in a somewhat tubercu- 
lated form, on the mucous membrane. More generally 
there is much irregular thickening, by organization of 
the lymph effused, and ulceration to a considerable ex- 
tent, found on dissection, and the patient is much ema- 
ciated before death takes place. 

This inflammation is most frequent in warm climates 
and seasons, when the secretions of the intestines have 
been long stimulated by heat, but is most generally ex- 
cited by exposure to cold and wet. It has been thought 
to result from the action of a peculiar Malaria, gene- 
rated in like manner as that which excites Intermittent 
Fever ; and there is no good ground for doubting, that 
in certain circumstances, and in certain constitutions, it 
may spread by contagion. We have therefore reason to 
think, that the inflammation producing the symptoms of 
Dysentery is occasionally of a specific character ; and 
when so, peculiarly dangerous ; but we know that the 
disease is very often dangerous, particularly when it ex- 
tends rapidly along the membrane, and is attended with 
much constitutional disturbance, — or, in warm climates, 
where complicated with disease of the liver, — although it 
may be only a healthy inflammation from cold. 

Although there are many cases of bowel complaint in 



326 OUTLINES OF PATHOLOGY AND PRACTICE. 



this climate with dysenteric stools, whicli subside readily 
under the alternation of laxatives and opiates, without 
loss of blood, yet in a well marked case of dysentery we 
should regard bloodletting as clearly demanded, its early 
use highly important, and general bloodletting as usu- 
ally preferable. Next to bloodletting (which should 
very often be repeated) opium in repeated doses, every 
three or four hours until the local symptoms abate, seems 
by far the most important remedy. The opium may be 
used alone, or combined with ipecacuanha , so as to pro- 
duce sweating, or with acetate of lead, particularly if the 
discharge of blood is great. The evacuation of the 
bowels by laxatives during the violence of the inflamma- 
tion may be most properly postponed ; but it is clearly 
beneficial to alternate the opiates with laxatives as the 
disease goes on,^^ — often repeatedly, when the quantity of 
feculent matter daily discharged is less than natural, and 
part of it scybalous. The mild laxatives, such as castor 
oil, solution of sulphate of magnesia with sulphuric acid, 
sulphur, bi-tartrate of potass, or rhubarb with calomel 
and ipecacuan, are usually quite sufficient for the pur- 
pose. In the advanced stages the quantity of feculent 
matter discharged usually shews that the laxatives are 
not required, and the opium in giyster or suppository is 
the most useful remedy. 

In the oTeater number of cPises seen in this coim- 
try in proper time and uncomplicated, this practice 
is successful ; and it seems obviously advisable not to 
use mercury so as to affect the mouth, because of the 
known risk of its exciting, especially if cold and wet be 
applied soon after it, an affection of the mucous mem- 
brane very similar to the dysentery itself. But there 
are a few cases in this climate, where dysenteric symj)- 



INFLAMMATIONS OF THE VISCERA, &C. 327 



toms, especially in comiectioii witli enlargement of the 
liver, becoming chronic and intractable under other 
treatment, have yielded when the mouth has been af- 
fected with mercury; and we have many statements 
from the warmer climates, where mercury may be given 
more safely, to shew that the specific action of mercury 
appears to arrest the inflammation even in its acute 
stage. Whether this may be only in the case of a spe- 
cific form of inflammation, is doubtful ; but certainly it is 
not the general fact in this climate, that any such de- 
cided efl'ect on the acute inflammation of dysentery re- 
sults when the mouth is afl'ected by mercury. On the 
contrary, an aggravation of the symptoms has certainly 
been sometimes observed. 

Some cases of organic disease {e. g. Stricture) of the 
Intestines, appear from their symptoms to originate in 
inflammation of the mucous membrane, and are attended 
throughout with symptoms nearly resembling dysentery, 
but in others the symptoms begin more gradually and 
insidiously, and the appearances on dissection are clearly 
distinct from the effects of inflammation. 

The convalescence from all inflammations of the in- 
testinal mucous membrane always demands much at- 
tention, on account of the frequent tendency to relapse ; 
to be guarded against only by constant warm clothing 
and other precautions against cold, — correcting imme- 
diately either costiveness or diarrhoea, — enjoining a very 
light diet at first, but gradually allowing a tonic diet and 
regimen, without permitting any excess. 



328 OUTLINES OF PATHOLOGY AND PRACTICE. 



Sect. 1Y .—Of Nephritis^ or luflammation of the 
Kidneys, and of the other Urinary Organs. 

This disease is seldom seen in the form described by 
Gullen — affecting one kidney, and indicated by fever, 
pain stretching along the ureter in that side, frequent 
voiding of very high or very full coloured urine, retrac- 
tion or pain of the testicle, and vomiting ; but there are 
cases, both of inflammation of the substance of the kid- 
ney and of Pyelitis, or inflammation of the pelvis and 
ureters, of which the first symptoms are nearly those 
stated, and which terminate in suppuration of the sub- 
stance of the kidney, in thickening of the membrane, 
effusion of pus, and of flocculent lymph upon it, or even 
in ulceration. In one variety of this inflammation, the 
ureter is obstructed, whether by the effects of the in- 
flammation itself, or by a calculus impacted in it, or by 
pressure of some neighbouring part ; and the upper part 
of the ureter, the pelvis and cavities being distended with 
purulent or sero-purulent fluid, the substance of the 
kidney is wasted by absorption, and it acquires the ap- 
pearance of a number of cysts filled with that fluid. 

In such cases, the symptoms are sometimes not distin- 
guished during life from those of peritoneal inflamma- 
tion ; but there are generally means of distinguishing 
them on careful examination, chiefly in the pain and 
tenderness being more limited, the urine being often for 
a time either bloody or albuminous, and the action of 
the bowels less affected. Such cases, when unconnected 
w^ith any permanent cause, are no doubt often success- 
fully treated by antiphlogistic remedies, without their 
exact nature ever being ascertained. 



INFLAMMATIONS OF THE VISCERA, &;C. 329 



It is important to remember that inflammation and 
suppuration of the kidneys, as well as of the lining mem- 
brane of the ureters and bladder, occur not unfrequently, 
without pain, in cases of injury of the spine, and palsy 
of all the lower part of the body. 

But the more frequent cases of inflammation of the 
Kidneys are of more chronic character, tend to different 
terminations, and are distinguished by less violent, though 
not less characteristic symptoms, and are found gene- 
rally to affect both kidneys alike. It has been stated 
lately by Kayer that alkaline urine, without obvious dis- 
ease of the bladder, depends frequently on chronic in- 
flammation of the kidneys ; and it is now well ascer- 
tained, by the elaborate investigations of Dr Bright, 
confirmed and extended by others, that when the urine 
is albuminous (coagulable both by heat and acids), and 
at the same time of low specific gravity, the kidneys are 
always diseased, usually in the form described as Granu- 
lar Degeneration, affecting their cortical substance, which 
admits of considerable variety of appearance, and in many 
cases is originally the result of inflammation; bearing ap- 
parently to healthy inflammation of the kidneys the same 
relation as the cirrhosis of the liver, or the atheromatous 
or osseous deposits on the lining membrane of the heart 
and aorta, or tubercles in the lungs, do to healthy in- 
flammations of these organs ; — i. e. frequently excited by 
that process, but always implying a peculiar predisposi- 
tion, inherent in the blood, and when that predisposition 
is strongest, requiring little or no inflammatory action 
to excite them. 

In some cases, the disease of the Kidneys, known by 
these marks, is attended with febrile symptoms, pains of 



330 OUTLINES OF PATHOLOGY AND PRACTICE. 



the back and abdomen, vomiting, and either rapid sinking 
(making the whole progress of the symptoms very similar 
to Peritonitis) or delirium, spasms and stupor, depending 
obviously on the retention and circulation of Urea in the 
blood, and tending to death in the way of Coma. Some 
of these cases are, and others are not, attended with 
Anasarca, and very scanty urine. In such rapidly fatal 
cases, the morbid granulated appearance of the Kidneys 
is usually found to be associated with enlargement and 
softening of their substance ; in some instances even the 
vascularity, enlargement, and softening of the Kidneys 
have been found without any granular deposits. Such 
cases often occur in convalescents from Scarlatina ; the 
symptoms of them may occur alone, or they may be at-- 
tended with symptoms of inflammation in other parts, 
chiefly the head or chest ; and when early recognised, 
they are frequently seen to subside completely under the 
full use of antiphlogistic remedies, and the urine gra- 
dually regains its natural qualities. 

But when cases of disease of the Kidneys, known by 
those qualities of the urine, are not seen at their com- 
mencement, or when they commence unattended by 
febrile or inflammatory symptoms, the anti-phlogistic 
treatment is ineffectual in correcting their characteristic 
indications, although it may often be advisable on ac- 
count of their complications. The most important facts 
ascertained as to the subsequent progress of cases in 
which this morbid state of the Kidneys exists, are the 
following. 

1. That when the urine, although albuminous and of 
low specific gravity, is in quantity greater than natural 
(so that the usual amount of solid matter may pass off 
from the kidneys in a given time), the general health may 



INFLAMMATIONS OF THE VISCERA, «&C. 



331 



be tolerably good for a considerable number of years ; 
although there is a liability to very various disease, 
making a very cautious regimen necessary. 

2. That many such persons are found to be simul- 
taneously affected with other diseases, chiefly of the 
liver or of the heart, which are originally of the same 
character, and which, of course, increase their liability 
to disease. 

3. That such persons are very liable, particularly on 
exposure to cold, to attacks of Dropsy. 

4. That they are also peculiarly liable (with or with- 
out such dropsical attacks)- to sudden inflammation, 
especially of the chest. 

5. That they are liable to organic diseases of the brain. 

6. That many of them are subject to sickness and 
vomiting, independently of liver disease, and especially 
to diarrhoea; those who are subject to the diarrhoea be- 
ing perhaps the least liable to the dropsical affections. 

7. That when the quantity of urine becomes less (as 
very generally happens in the progress of such cases), 
and its specific gravity and the quantity of solid matter 
and even of albumen in it diminish at the same time, we 
must expect, not only that these complications will be- 
come more frequent and intractable, but that they will 
be attended with more or less of the characteristic effects 
of the presence of Urea in the nervous system, particu- 
larly drowsiness, spasms, indistinct vision, &;c. and ulti- 
mately delirium and fatal stupor. 

The tendency to so many and various other diseases, 
in connection with this disease of the Kidneys, is obvi- 
ously very much dependent on the great alteration which 
has been ascertained to take place in the constitution of 
the blood during it, viz. diminution of the quantity, first 



332 OUTLINES' OF PATHOLOGY AND PRACTICE. 



of its albumen, and afterwards, to a mucli greater extent, 
of its colouring matter, — implying a corresponding debi- 
litating effect on all vital action. — (See Cliristison on 
Granular Degeneration of the Kidneys.) 

In a few cases the morbid condition of tbe Urine, 
after having been established, and after the antiphlogistic 
remedies, to the extent which the symptoms seemed to 
justify, have failed of effect upon it, has diminished or 
disappeared under other remedies, — the diaphoretic regi- 
men and medicines in some cases, the tonic regimen 
and medicines in others, the use of Iodine or the Hydri- 
odates, and even the cautious use of Mercury ; but it is 
always to be obserjed, that Mercury is very apt to act 
violently and injuriously on the mouth and on the bowels 
in those who have this disease, and most generally fails 
of any good effect upon it, particularly when, as often 
happens, there are marks of the scrofulous habit in the 
patient. 

The Dropsy which is connected with this disease of 
the kidneys, if uncomplicated with other organic disease, 
often disappears under the use of laxatives and diuretics, 
among which the Bi-Tartrate of Potass and Digitalis 
have appeared peculiarly successful. If the attacks of 
Dropsy are preceded or attended by any indications of 
inflammation, particularly in the chest, the effect of such 
remedies is very generally decidedly aided by Blood- 
letting. 

The other complications of this disease require reme- 
dies to be applied to themselves, always with the caution, 
that the constitution is one in which organic disease ex- 
ists, affecting an organ which is knqwn to be connected, 
although in a way still obscure, with the assimilation of 
aliments. In the advanced stages, palliative treatment 



INFLAMMATIONS OF THE VISCERA, &C. 333 

only is admissible ; tlie diarrhoea ought not to be sud- 
denly arrested, and the course of the symptoms, when 
it is checked, should be carefully watched, because it is 
likely that much of the Urea (which is circulating in 
the blood) may be discharged in this way, and because 
those who have much of this, accompanied by the renal 
disease, have seldom much of the Comatose tendency. 
Under the use of Blisters and Purgatives, this latter 
termination of the disease seems sometimes to be averted 
for a considerable time. 

The Cystitis, or inflammation of the mucous mem- 
brane of the bladder, is seen sometimes in the acute 
form ; more frequently in the chronic ; and is known 
by pain in the situation of the bladder ; sometimes very 
violent ; frequent and painful passing of urine, with 
straining, — exactly similar in pathology to the tenes- 
mus from inflamed Rectum, — and the discharge of ropy 
mucus with the urine, which in the more chronic, or 
more advanced cases, becomes purulent ; and this last 
discharge is converted so readily into Ammonia, that the 
urine is often alkaline when discharged. With those 
in severe and acute cases, there is general fever — ge- 
neral abdominal pain, — vomiting, and sometimes tenes- 
mus. 

This disease is most commonly combined with others 
which fall under the care of the surgeon, — Calculus, 
enlarged Prostate, Gonorrhoea or Strictures, — but 
may occur, and may go to ulceration, generally of fun- 
gous character, and be attended with copious hsema- 
turia, especially on exertion, although unconnected 
with any of those diseases. When uncomplicated, or 
demanding remedies for itself, independently of the pe- 
culiar treatment of these diseases, it is benefited by the 

3 



334 OUTLINES OF PATHOLOGY AND PRACTICE. 



aiitipUogistic remedies generally, especially by repeat- 
edly leeching the perinseum — by rest, and the antiphlo- 
gistic regimen — by diluent and mucilaginous drinks — 
by the warm bath, — more generally by the frequent 
and often long continued use of opiates, — especially the 
opiate enema, and in the quite chronic state (that call- 
ed Catarrhus Vesicae), by astringents, particularly the 
Uva Ursi, — the Diosma, — the Pareira, — preparations of 
Iron, — the Turpentines and Copaiba, even the Cantha- 
rides. 

It occurs frequently as an effect of Paraplegia, and 
then, of course, cannot require the anodynes, but may 
be partially benefited by the astringents. 

Sect. V. — Of Inflammation of the Uterus. 

The acute form of this inflammation has seldom 
been distinctly recognised, excepting in combination 
with the symptoms of Peritonitis, supervening generally 
on suppression of the Lochia soon after delivery, when 
it demands no peculiarity of practice. It has been sup- 
posed, in such cases, that when the fever takes a more 
typhoid form than usual, the substance of the uterus 
has been inflamed ; but it has been already stated, that 
in one form of the peritoneal inflammation, both after 
delivery and at other times, the attending fever is in 
several respects typhoid, independently of any such com- 
bination. 

It is certain that in most of the cases of inflamed veins, 
and white swelling of the limb after delivery, the in- 
flammation has begun in the veins of the uterus, and 
extended along some of them to the iliac veins, even 

6 



INFLAMMATIONS OF THE VISCERA, &C. 



335 



when tliere have been no urgent symptoms at the uterus 
itself. 

The cases of inflammation of this organ, which are 
more generally recognised, are the sub-acute and chronic 
inflammations, — of which a certain degree probably exists 
in every case where there is sudden and painful sup- 
pression of the menses ; and of which there are some 
varieties, and several distinct terminations, although 
often distinguished with difficulty, either from that form 
of Neuralgia, called Irritable Uterus, on the one hand, 
or from incipient Scirrhus, or other organic disease, on 
the other. 

Inflammation of this character may occur on the ex- 
ternal surface of the Uterus, and adjoining portions of 
peritona3um only, without extending over the other peri- 
toneal surfaces, or causing the usual symptoms of Peri- 
tonitis ; and from the frequency of adhesions at these 
parts found on dissection, in patients who had never 
been treated for inflammatory complaints, we may sus- 
pect that this is a more frequent occurrence than it has 
been thought. It may occur in the muscular substance of 
the uterus, and lead to permanent enlargement; and it 
may occur on the internal surface, and lead, either to 
frequent purulent discharge, particularly at the men- 
strual periods, or to ulceration, independent of any scir- 
rhus or other morbid deposit, at the Os Uteri ; or to 
effusion of layers of fibrin on this surface, which may be 
thrown off repeatedly, or may accumulate in the interior, 
and be thrown off in mass. All these lesions are pretty 
frequent results of chronic inflammation here ; the 
cause of which is exceedingly various, and the sympa- 
thetic pains, dyspeptic and hysterical affections attending 
these, equally various. Such inflammations may always 



336 OUTLINES OF PATHOLOGY AND PEACTICE. 



be suspected wlien, witli some irregularity of menstrua- 
tion, and some degree of fever, — certainly independently 
of conception, there is much of the bearing down pain, ex- 
tending along the thighs, and some appearance either of 
coagula of blood, or fibrin, or of purulent matter, in the 
discharges. In many cases the nature of the disease 
may be more satisfactorily ascertained by examination by 
the Vagina ; and by local bleedings, especially at the Os 
Uteri itself, blistering on the Sacrum, and other anti- 
phlogistic treatment, it may be effectually relieved. But 
after a time, even in those strictly inflammatory cases, 
evacuations become unavailing, and astringent and 
anodyne apphcations, and a more tonic plan of treat- 
ment, become advisable. And it is always to be re- 
membered, that in the Irritable Uterus, or Hysteralgia, 
there may be much and long-continued tenderness at 
the Os Uteri, with much sympathetic affection of other 
parts, and much loss of muscular strength, which does 
not go on either to ulceration, or enlargement, or 
change of texture, and is not benefited at all by evacua- 
tions, nor even by long-continued rest, but chiefly by 
anodynes, and a gently tonic plan of treatment. 



( 337 ) 



CHAPTER V. 

OF INFLAMMATIONS OF THE NERVOUS SYSTEM, AND 
ORGANS OF SENSE. 

Sect. I. — Of Inflammation of the Brain. 

The acute form of Phrenitis seldom exhibits the set 
of symptoms which are enumerated by Cullen and other 
systematic authors — the intense headache, flushing of 
face and eyes, high delirium, and frequent and full pulse. 
These symptoms are, in fact, more severe in the begin- 
ning of some of the strictly febrile diseases, where they 
are frequently succeeded by others of a very different 
character, and which do not indicate any inflammation 
in the brain. 

That there should be great difficulty in practice, in 
fixing on symptoms which clearly indicate inflamma- 
tion within the cranium, is easily understood, when 
we consider what is known to us from the Anatomy 
of the parts, both in the sound and diseased state, 
and from their Physiology, viz. that inflammation there 
may attack very different textures, and with very va- 
rious degrees of intensity and rapidity ; and that the in- 
jury done, in any way, to any part of the nervous mat- 
ter superior to the medulla oblongata, has no definite or 

Y 



338 



OUTLINES OF PATHOLOGY AND PRACTICE. 



uniform effect on any of the functions which we ascribe 
to the nervous matter. From these considerations, it is 
natural to expect that both the febrile symptoms and the 
indications of disordered function of the parts of the 
nervous system will be very various, and that we must 
judge, in regard to inflammation in this part, even more 
than in others, by attention to the combination and suc- 
cession of various symptoms, not by trusting to patho- 
gnomonics. 

In the best marked cases of active inflammation 
within the cranium, — such as bear evacuations best, and 
are most generally and decidedly benefited by them 
when used' early, and carried to a due degree, — the first 
symptoms are fever, of various degree, with sharp, shoot- 
ing pain of head, impatience of light and sound, sickness 
and vomiting, and great aggravation of the uneasy feel- 
ings on assuming the erect posture. The pulse is firm, 
often peculiarly sharp, but seldom very frequent, and in 
some cases, almost from the beginningj it is glower than 
natural. 

If these symptoms are not quickly relieved by reme- 
dies, one or more of the following soon shew themselves, 
marking more distinctly, although variously, that the 
texture of the brain, and of the organs of sense and vo- 
luntary motion, has been somewhere injured ; delirium, 
generally attacking in sudden fits ; or instead of delirium, 
partial and temporary loss of recollection ; spasm, like- 
wise usually sudden and violent ; dilatation of pupil, 
squinting, or blindness, more or less complete ; paraly- 
sis, generally partial, sometimes temporary ; and drow- 
siness or coma, sometimes general and profound, some- 
times incomplete, or graduating into mere absence of 



INFLAM3IATI0NS OF THE NERVOUS SYSTEM, &C. 339 



mind, and inattention to surrounding objects. These 
symptoms are attended by characteristic, but somewhat 
various changes in the pulse, most generally by slowness 
or irregularity, followed by extreme rapidity. 

The sudden attack, and frequently complete and even 
repeated abatement, of the delirium, spasms, and coma, 
are important as often contrasting remarkably with the 
more uniform course of those symptoms in idiopathic 
fever. 

But there are many cases, some equally acute, others 
much more chronic, in which the symptoms deviate con- 
siderably and variously from this more perfect type, and 
are, in the earlier stage, much less easily recognised. 
The principal varieties met with may be referred to the 
following heads : — 

1. In some cases the fever is more marked, and the 
local symptoms less urgent, than usual ; there is no vio- 
lence of pain, nor vomiting, nor sharp nor irregular 
pulse, and for some days the case resembles mild con- 
tinued fever, until some of the indications of more severe, 
and generally more partial^ affection of the functions of 
the brain than are usual in fever, shew themselves. 

2. In others, in the beginning, the headache is more 
permanent and urgent, and hardly any febrile symptoms 
exist. 

3. In others the first symptom that excites any at- 
tention is a general convulsion. 

4. In others temporary delirium, or blindness, or 
partial palsy, appears as one of the first symptoms ; and 
we know from dissections that either may appear as a 
result of inflammation in its first stage. 

5. In others, especially in children, the disease comes 



340 OUTLINES OF PATHOLOGY AND PRACTICE. 



on, sometimes rapidly, sometimes very gradually, as a 
sequela of others — of chest affections, such as hooping- 
cough, of fever, of the febrile exanthemata, and per- 
haps still more frequently of the Febris Infantum Re- 
mittens ; which last complication is the more important, 
as the disease is then often preceded by less exhaustion, 
and the antiphlogistic remedies may be safely and bene- 
ficially applied to the abdominal as well as the head 
symptoms. 

6. In others the disease obviously supervenes on more 
chronic affection of the bones of the head. 

It is probably a general fact, that the fever, pain, 
delirium, and general excitement, are more active in the 
early stages of inflammation, affecting the membranes 
than the substance of the brain ; but to this there are 
certainly exceptions. 

The Diagnosis of cases of Inflammation of the Brain 
is often difficult, at least in the earliest and most re- 
mediable stages, but may generally be made out, partly 
by attention to the particulars above noticed as to this 
inflammation, and partly by observing the absence of the 
peculiar symptoms of other febrile diseases, with which 
it might be confounded. For example : The neuralgic 
and hysterical pains of head which occur in some con- 
stitutions, are sometimes distinguished from this, or 
from other inflammations, with much difficulty, and 
only by attention to the marks of those constitutional 
and non-febrile diseases, and sometimes only by trial 
of the effects of remedies ; for it must not be supposed, 
that those who are affected with Hysteria or Neuralgia 
are not susceptible of this or other inflammations. 

It may generally be observed, that the cases which 



INFLAMMATIONS OF THE NERVOUS SYSTEM, &C. 341 



are most insidious in their progress, and recognised with 
the greatest difficulty, are those in which the antiphlo- 
gistic treatment is least effectual. 

The Hydrocephalus of children, as described by many 
practical authors, shews all the variety of symptoms 
above stated, which are very frequently fatal within 
two or three weeks. On dissection, the most uniform 
appearance is effusion of serum (deprived in a great 
measure of albumen) into the ventricles of the brain ; 
generally attended by unusual dryness of the mem- 
branes on the surface, for which a reason sometimes ap- 
pears in closing of the opening into the fourth ventricle 
by lymph. From this appearance, taken alone, we 
should not be entitled to infer that the disease had been 
inflammatory ; but as we find, in a large proportion of 
cases, which during life have presented the symptoms 
under consideration, the unequivocal marks of inflamma- 
tion co-existing with this effusion into the ventricles, 
and sometimes existing without it ; and as we find, also, 
that the chief symptoms in these undoubtedly inflam- 
matory cases, are just the same as in those which pre- 
sent, on dissection, the effusion only ; we can have no 
reasonable doubt that the effusion, when preceded by 
those symptoms, is to be regarded as an effect of a 
diseased action either truly inflammatory, or so nearly 
resembling inflammation as to demand the same j)rac- 
tical consideration. Nor is there any difficulty in under- 
standing, that inflammatory effusion should be fatal in 
its earliest stage, and therefore without other indica- 
tions of inflammation in the dead body, when it oc- 
curs in an organ where pressure from rapidly effused 
fluid is a sufficient cause (as Physiology instructs us) 
for fatal coma ; — just as it is a sufficient cause for death 



842 OUTLIi C.S OF PATHOLOGY AND PRACTICE. 

by asphyxia when occurring in tlie cells of both lungs 
at once, or behind the membrane of the glottis. It 
is likewise easy to understand, that in other cases, 
effusion into the ventricles may take place much more 
slowly, in connection with other kinds of diseased ac- 
tion, and that then, in accordance with principles 
known in Physiology, it may go to a great length, either 
without causing pressure at all on the substance of the 
brain, or without causing such rapid pressure as may 
materially injure any of its functions. This seems es- 
pecially to occur in old persons ; and in them the 
symptoms found in connection with the effusion into the 
ventricles are much more various than in young subjects. 

The distinctly inflammatory appearances which are 
found within the cranium in a very large proportion of 
cases, of which the symptoms have been such as above 
noticed, are the following : — 

1. Effusion of lymph, or of " concrete pus," on the 
membranes, most generally, as might be expected from 
its greater vascularity, on the pia mater. 

2. The Ramollissement rouge, or softening with red 
colour, of a portion of the cerebral substance. 

3. The Ramollissement jaune, or sof telling with 
diffuse purulent infiltration of some portion. These 
softenings are often attended with effusion of blood into 
the affected portion, which effusion has no doubt some- 
times been the cause, but in many cases, we have rea- 
son to think, has been the effect, of the partial disorgan- 
ization. 

4. The formation of a circumscribed abscess in some 
part of the cerebral matter. 

5. Induration, with increased vascularity of some por- 
tion » 



INFLAMMATIONS OF THE NERVOUS SY TEM, &C. 343 



6. The simple softening, or softening witliout change 
of colour, of some portion. 

The two last appearances are the result of more 
chronic inflammation than the others, and the last is 
probably often the result of mere perversion of nutri- 
tion, without inflammation, particularly as it appears to 
be, in some instances, unattended with any appearance 
of exudation globules^' in the diseased part.* All the 
forms of softening of the brain, but particularly the 
last, when found in connexion with diseases of the ar- 
teries at the base of the brain, may be supposed to be 
the efl'ects of a peculiar inflammation, leading rapidly 
to disorganization or gangrene, as in other parts of the 
body, where there are ossified arteries. 

The serous eff'usion, and all the marks of inflammation 
within the head, are very frequently complicated with 
tubercular deposits on the membranes, or in the sub- 
stance of the brain ; and the connection of this inflam- 
mation with the tubercles, appears to be the same as 
in other parts of the body ; i. e.^ it is never to be re- 
garded as their sole cause, but often as their exciting 
cause ; while, on the other hand, the tubercles, pre- 
viously existing, are, perhaps, more frequently than in 
other cases, to be considered as powerful predisposing 
causes of the inflammation ; which may be held to be 
" intercurrent" during their progress. The same ob- 
servation may, indeed, be applied to the connection of 
Inflammation of the Brain with very various other 
forms of morbid growths, more organized than Tuber- 
cles, — often found within the cranium,- — and very va- 
riously injuring the functions of the brain. 

* See Bennett " On Inflammation of the Nervous Centres." 
Edinburgh Medical Journal, October 1842, 



344 OUTLINES OF PATHOLOGY AND PKACTICE. 



The remote causes of this disease are very much 
those of inflammations in general : the scrofulous dia- 
thesis being the most important predisposition : and it 
is important to remember the frequent effect, in ex- 
citing it, of injuries of the head, even such as have ap- 
parently given little uneasiness, — of suppressed evacu- 
ations [e, g. of the Menses in women, or of that from 
Porrigo in children), — and of previous irritation and in- 
flammation, particularly in the abdomen. 

The Prognosis is always to be regarded as doubtful, 
and in all the more complex and insidious cases, or in 
cases which are not recognised, or neglected, in the com- 
mencement, as very unfavourable. 

Many well marked cases, however, particularly those 
in which the early symptoms are the most distinct and 
characteristic, subside completely under active depletion; 
particularly full and repeated bloodletting and purging. 
The bleeding should be both general and local; but 
the former is by far the most important ; and it may 
be laid down as a general rule, to trust no case to the 
local bleeding only beyond the age of five years. There 
are some cases, particularly in adults, in which the in- 
flammation lasts very long, or returns very frequently, 
and ultimately abates completely, under repeated local 
or even general bleeding, without stupor, delirium or 
spasms, ever supervening ; while, in others, those results 
of the disease shew themselves within a very few days. 

The purgatives are by far the most important auxi- 
liary ; of these the croton oil is often the most conve- 
nient ; and it is important to remember the observation 
of Dr Abercrombie, that he has seen more recoveries 
from bad symptoms of affection in the head under full 
purging, than any other treatment ; implying, not that 



INFLAMMATIONS OF THE NERVOUS SYSTEM, &C. 345 



this remedy is more effectual than bloodletting, but that 
it may be effectual in the advanced stages of the disease, 
after coma and spasms have come on, and when the loss 
of blood is very generally (according to what was for- 
merly stated) of no avail. 

The quantity of purgative medicine required to cause 
full evacuation of the bowels is sometimes very great ; 
but when bloodletting is employed early and fully, this 
torpid state of the bowels is much less observed than when 
the chief reliance is placed on purging. The stools are 
in some cases distinctly, although variously, of morbid 
character, and this is, to a certain degree, an additional 
reason for purging ; but the good effects of the purgatives 
depend obviously for the most part on their c^mVan^ power, 
and are often observed when the stools are quite natural. 

The full action of Mercury has so frequently been 
seen wholly ineffectual in this disease, that it is not right 
to place any reliance on it, in cases where the more 
active modes of depletion may still be employed ; and it 
is certain that in some constitutions, the first constitu- 
tional effect of mercury given in this disease is attended 
with an aggravation of the symptoms ; but in cases, 
where the symptoms have become somewhat chronic, 
and in those which are connected with disease of the 
bones of the head, it appears sometimes decidedly bene- 
ficial ; recovery from very bad symptoms, resisting other 
means, having taken place under its use, either in dif- 
ferent preparations, given internally, or in the form of 
inunction. It may generally be expected, that if it 
is to act effectually, the improvement will be perceived 
very soon after the effect of the mercury on the system 
has appeared. 

Repeated blistering and other counter-irritants appear 



346 OUTLINES OF PATHOLOGY AND PEACTICE. 



sometimes decidedly useful wlien the symptoms become 
somewhat chronic, the febrile symptoms having abated. 
In the earlier stages shaving and applying cold assidu- 
ously to the head, with warm fomentation of the feet 
and legs, are the better practice. 

. In some cases sedative medicines, as digitalis, colchi- 
cum, and tartar emetic, have been thought useful auxi- 
liaries ; but the vomiting in the early stages generally 
contra-indicates these, and little reliance should be placed 
on them. 

Opiates should be very generally avoided, although 
there are cases, where pain of head continues after the 
febrile symptoms have abated, and where there is no 
tendency to coma, in vv^hich they have seemed beneficial. 

The rigid antiphlogistic regimen is very generally 
proper both during and for some time after the disease ; 
but there are cases in which, after full evacuations, and 
reduction of the febrile state, headaches, or a tendency 
to stupor, abate under cautious stimulation. 

The -most important case of this kind is that to which 
the term Hydrocephaloid disease has been applied, — 
occurring in children, — where a marked tendency to 
stupor, generally much vomiting, sometimes dilatation, 
sometimes contraction, of the pupil, co-exist with cold- 
ness of the surface and a rather feeble pulse, and are 
found, on inquiry, to have come on after weakening 
causes, and especially after diarrhoea of some standing. 
In this case, small and frequent doses of wine, brandy, 
and ammonia, with opiates if the diarrhoea continue, and 
sometimes blistering the head, have been often found 
effectual. 

It may be judged, from what has been said above, 
that in many cases of various organic disease within the 



INFLAMMATIONS OF THE NERVOUS SYSTEM, &C. 347 



cranium, causing various affections of Sense, Intellect, 
and voluntary Power, — and likewise in various disorders 
of those functions, not necessarily connected witli or- 
ganic disease — e, g. epilepsy, chorea, delirium tremens, 
mania, — attacks of inflammation of the brain, most ge- 
nerally chronic or subacute, take place in connection, 
sometimes with the commencement, sometimes with 
repeated aggravation, of those diseases ; and therefore 
that the antiphlogistic regimen and remedies may fre- 
quently be employed, in the course of those diseases, 
with good effect. But the use of strong antiphlogistic 
remedies must be limited to the times, occurring oc- 
casionally in these complaints; when the circulation is 
strong, and more or less of the symptoms either of local 
inflammation or inflammatory fever are present ; and 
when these are not present, those remedies may be hurt- 
ful ; and even the antiphlogistic diet and regimen, particu- 
larly in the cases of strictly mental disease, may become 
useless or injurious. The treatment ought then to be 
adapted to the existing state of the functions of the brain, 
not to any action, of the nature of inflammation, which 
can be supposed to have produced that state. 

It is even well known that in some cases of functional 
disease of the brain and nervous system, or in the most 
advanced stage of those which have been in the first 
instance inflammatory, — ancj, where a certain degree of 
organic lesion exists, — the stimulating remedies may be 
decidedly useful, at least as the best auxiliaries to the 
treatment adapted to the disordered condition of the ner- 
vous system. The delirium tremens afl'ords many exam- 
ples illustrating this principle. But there are. many cases 
of chronic disease of the nervous system in which loss 
of blood is injurious, but where the careful and judi- 



348 OUTLINES OF PATHOLOGY AND PRACTICE. 



clous use of purgatives, combined or alternated with the 
tonic plan of treatment, is successful. 

Sect. II.- — Of Inflammation of the Spinal Cord. 

This inflammation may be expected to shew itself by 
fever, pain, and injury of the functions of the cord, i. e, 
of Sensation and voluntary or instinctive Motion, or of 
those actions to which the name of Reflex or Sympathe- 
tic has been given ; and this accordingly has been ob- 
served, but with very great variety, no doubt depending 
on the varying - acuteness* and extent of the inflamma- 
tion, and on its being seated, in some cases, chiefly or 
solely in the membranes (spinal meningitis) ; in others 
in the nervous matter (myelitis.) These varieties are 
such, and the inflammation of these textures is so often 
combined, that it is to no purpose to treat of them sepa- 
rately j but it may be stated, that more of palsy may be 
expected in the latter case, and more of pain and spasm, 
especially tetanic spasm, in the former. 

The disease often proceeds from injuries aficcting the 
spine ; in other respects nothing peculiar has been as- 
certained in regard to its remote causes, except that a 
peculiar tendency to it has appeared to be given by ve- 
nereal excesses. • 

There are all possible varieties as to the rapidity of 
the attack, the degree of febrile action attending it, and 
the intensity of the pain. Indeed in cases of pure my- 
elitis, going on to palsy, there may be no pain what- 
ever. 

The pain is often hardly complained of in the back, 
jbut referred rather to the extremities of the nerves issu- 



INFLAMMATIONS OF THE NERVOUS SYSTEM, &C. 349 



ing from the affected part of the cord, therefore to the 
limbs, to the sides, or abdomen ; and frequently it is 
complained of chiefly as encircling the body like a tight 
ligature. 

It is often subject to remarkable remissions. The pain 
is very generally attended and characterized by more or 
less of spasm^ often brought on by motion, and taking 
generally somewhat of the form of tetanic rigidity. 
There is also very often tenderness at the affected part 
of the spine, dependent apparently on affection of those 
of the nerves there arising, which come soonest to the 
surface of the body. In some cases, where the mem- 
branes only are concerned, the'se symptoms, attended by 
much febrile action, more or less resembling the Hydro- 
cephalus, are followed by coma and death, without any 
partial palsy shewing itself, but more frequently, espe- 
cially when the substance of the cord is affected, they 
are followed by palsy of sense or motion, or both, usually 
of the lower limbs, chiefly or solely, with which, how- 
ever, spasmodic action, and often tetanic spasms of the 
palsied limbs, are generally associated. 

In some even acute cases the palsy is preceded by very 
little either of pain or fever ; and its accession takes 
place sometimes rapidly, sometimes very slowly and in- 
sidiously. 

The actions of Respiration are often variously affected, 
and in urgent cases the loss of power in those of the re- 
spiratory muscles which are moved by the dorsal portion 
of the cord, and its continuance in those which are 
moved by the phrenic and cervical nerves, are striking 
and characteristic. 

The bowels are generally moved with difficulty ; and 
the act of voiding the urine, in gome cases, is much and 



350 OUTLINES OF PATHOLOGY AND PRACTICE. 



somewhat variously affected, there being generally re- 
tention in the first instance, followed by involuntary 
dribbling, and the urine becoming, after a time, ammo- 
niacal and loaded with purulent matter, from the se- 
condary inflammation of the mucous membrane formerly 
noticed. 

In the more acute cases, gangrene of some of the pal- 
sied parts undergoing pressure, often comes on very 
rapidly. 

The heart's action and circulation are often peculiarly 
affected, as might be expected from what is known of 
the effect of injuries of the spinal cord upon them. There 
is often strong pulsation at the heart, without corres- 
ponding strength of pulse at the wrist, and where the 
febrile symptoms have become typhoid, with much ex- 
hausting perspiration. In the most rapidly fatal cases, 
there is early and unexpected failure of the heart's 
power ; and probably it is chiefly in consequence of the 
impression made directly on the circulation that well 
marked cases of this inflammation are very generally 
fatal, although with very various rapidity. 

There are many cases, however, in which we have 
reason to think that this inflammation has occurred par- 
tially, and in a more chronic form, which terminate fa- 
vourably ; and this has been especially observed of these 
cases in which the functions of the bladder are little af- 
fected. 

It is by this inflammation in a chronic form, super- 
vening on the disease of the vertebrae, that caries and 
protrusion of any part of the spine are so often followed 
by Paraplegia. 

The morbid appearances found after this inflammation 
are either effusion of lymph or pus between the mem- 



INFLAMIVIATIOISS OF THE NERVOUS SYSTEM, &C. 351 



branes of tlie cord, or softening or hardening, generally 
with discoloration, of the cord itself, similar to what is 
seen in the brain ; the softening being generally, although 
not exclusively, the result of the more acute inflamma- 
tion. In many cases, when symptoms of affection of 
the brain have occurred, there is effusion into the ven- 
tricles, and even lesion of the brain itself ; and in many 
the inflammatory effusions are mixed with tubercular 
deposits, or with other forms of organic disease. 

The fatality of the disease, in its acute form, has no 
doubt depended partly on the difficulty of recognising it 
in its earliest stage ; but, on the other hand, it may be 
urged that this difficulty, as in the case of Hydrocepha- 
lus, is probably chiefly felt in cases where the constitu- 
tion is unsound, and the effect of remedies is slight. In 
well-marked cases, and in healthy constitutions, the ef- 
fect of early repeated bloodletting, general and local, 
has often been very decided. In all cases full and re- 
peated purging is proper, and in the more chronic cases, 
either repeated blistering, or the counter-irritation of 
issues, — sometimes even the slighter or more superficial 
irritation of the Tartar Emetic or Croton oil, — has often 
appeared beneficial, and along with this some have 
thought they derived benefit from the use of Mercury 
to affect the system. In scrofulous habits this last re- 
medy must be used with much caution. 

In the later stages, and in the more chronic cases, a 
relaxation of the antiphlogistic regimen, and cautious 
use of the tonic plan, as to air, exercise, and diet, be- 
come often undoubtedly serviceable. 

The difficulty in recognising, and therefore treating 
this disease, depends very much on the frequency of the 



352 OUTLINES OF PATHOLOGY AND PEACTICE, 



state to which the name of Spinal Irritation has lately 
been given, in which many of the symptoms of this in- 
flammation are very exactly imitated — particularly the 
pain and tenderness over the vertebrae, and the pains of 
the chest, abdomen, or sides— sometimes the spasms, and 
even the partial palsy, — all of which, however, coexist- 
ing with various indications of nervous irritability, with 
Hysteria and Neuralgia, are known to exist indepen- 
dently of inflammation, and in constitutions likely to be 
injured by much loss of blood. 

This state of the system is almost peculiar to women, 
especially to those in whom the menstrual discharge is 
suppressed, irregular, or excessive ; and may in general 
be distinguished by attention to the history of the case, 
the known constitution of the patient, and the accom- 
paniments of the pain. But it is farther to be observed, 
that severe and recent cases of that affection seem often 
connected with a subacute inflammation, and are bene- 
fited by at least local bleeding and counter-irritation. 
And it is farther to be kept in mind, that in cases 
which for a long time presented only the indications of 
Neuralgia and Hysteria, unequivocal indications of le- 
sion of the spinal cord (such as we have reason to think 
must have been preceded by some form of inflammation) 
have frequently presented themselves. 



Sect. III. — Of Ophthalmia^ or Inflammation of the 

Eyes, 

It is now generally agreed, that the distinction drawn 
by CuUen of the varieties of this inflammation, as aff'ect- 
ing especially the membranes or the eyelids, is insuffi- 



INFLAMMATIONS OF THE NERVOUS SYSTEM, &C. 353 



cient for practical purposes ; and that the following 
distinctions demand careful study. 

.1. According to the precise seat of the disease ; the in- 
flammation chiefly afl'ecting the Tunica Conjunctiva may 
be distinguished by the irregular tortuous appearance of 
the vascularity, by the most vascular part being moveable 
under the finger, by the pain being felt superficially and 
chiefly on moving the eyelids, and the discharge soon 
becoming opaque, glutinous, or even puriform ; in the 
most violent cases by the great swelling of the Conjunc- 
tiva called Chemosis. The inflammation of the Sclero- 
tica is distinguished by the enlarged vessels being deeper 
seated, less tortuous, most of them running parallel, 
and in a radiating form, to form a zone at the edge of 
the cornea ; the pain deeper seated and extending more 
to the temple, around the eye, and often over the side 
of the face and head ; with a less opaque and less glutin- 
ous discharge. The inflammation of the Cornea is shewn 
by specks of opacity, sometimes irregularity of surface, 
and partial vascularity. That of the Iris by the zone of 
enlarged vessels formed around the edge of the cornea, 
and dipping inwards towards the Iris, and more decidedly 
by its change of colour, diminished mobility, and irregu- 
larity from lymph eff*used upon it, even at an early pe- 
riod. That of the Hetina, or other internal parts, by 
pain and impatience of light, without visible inflamma- 
tion. 

II. Again, as to the important distinctions which de- 
pend on the cause of the inflammation ; the most common 
form depending only on cold, especially however applied 
after the heat and strong light of summer have cam- 

z 



354 OUTLINES OF PATHOLOGY AND PRACTICE. 

menced, is tlie inflammation of tlie Conjunctiva, or of 
the Sclerotica, what have been called the Catarrhal 
or Rheumatic Ophthalmia, or the combination of the 
two, which threatens the sense of sight only inasmuch 
as it leads to opacity of the cornea, generally pre- 
ceded by the appearance of pustules there. If this in- 
flammation occurs in a scrofulous habit, we have the 
Strumous forai of inflammation of the eye-ball, most 
common in children, often combined with that of the 
eye-lids, but which is distinguished by the impatience of 
light, greater in proportion to the other symptoms, and 
particularly to the vascularity, than in any other form, 
and by the frequency either of pustules, or of general 
inflammation, of the cornea. 

Again, when the inflammation is most distinctly con- 
nected with Rheumatism, it usually afl'ects one eye only^ 
is more distinctly remitting (the exacerbations at night) 
and attended with less aff'ection of the conjunctiva, and 
with more pain and tenderness of the temple and cheek 
than in other cases. 

From the syphilitic poison more frequently than from 
any other cause, but sometimes from other causes (as 
the use of mercury), and sometimes idiopathically, we 
meet with the Iritis, attended generally with frequent 
paroxysms of acute pain, and tending to injure or de- 
stroy sight, partly by reason of the lymph thrown out 
on the iris, and often forming adhesions between it and 
the lens, — partly, in many cases, by the accompanying 
afl'ection of the retina, producing one form of Amaurosis^ 

The most violent form of the disease is the Purulent 
Ophthalmia, proceeding generally either from the infec- 
tion from an eye similarly afl'ected, or from the poison of 
gonorrhoea, attended with much of the chemosis, and apt 
to go on, in a very few days, to sloughing and destruc- 



INFLAMMATIONS OF THE NERVOUS SYSTEM, 6iC. 355 

tioii of the cornea, — tlie same result as follows more 
slowly, but still more surely, from that inflammation of 
the conjunctiva which results from palsy of the 5th nerve. 

All forms of the disease are much more chronic in 
some cases than others, and the repetition of the reme- 
dies must be regulated by what is observed as to their 
course in this respect. 

They may all derive gi-eat benefit, in the early stage, 
from bloodletting, and in severe cases, especially where 
there is well marked constitutional fever ; — from general 
bloodletting, and from repeated purging and the strict 
antiphlogistic regimen ; but the purulent ophthalmia is 
that in which the general bleeding must be carried far- 
thest, and repeated most frequently and at shortest in- 
tervals, to avert the sloughing of the cornea, as indeed 
is generally indicated by the violence of the pain and 
fever. In this form especially, the nauseating doses of 
tartar emetic are found a useful auxiliary in restraining 
the vascular action and inflammation. 

In all the forms, during the greatest violence of the 
inflannnation, warm soothing applications, decoction of 
poppies, warm water, cream, and unctuous applications 
to the eyelids, give the most relief. When the pain is 
slight or its violence over, the astringent or even gently 
stimulating applications become useful ; the solutions of 
alum, of acetate of lead, of sulphate of zinc, and weak 
solution of bi-chloride of mercury, are to be used as 
washes, or a stronger solution of the nitrate of silver 
or the vinum opii dropt occasionally into the eye ; and 
the ointments applied to the eyelids, should contain a 
little of the mercurial salts. 

In the rheumatic form, diaphoretics, opiates at night, 
— as some think calomel with opium,— -blisters behind the 



356 



OUTLINES OF PATHOLOGY AND PEACTICE. 



ears, colchiciim, and certainly when the disease remits 
distinctly, the quinine in full doses during the remission, 
are often apparently more beneficial than the loss of 
blood. Nearly the same remedies, particularly the 
stomachic medicines, careful attention to the state of 
the bowels, the tepid bath at night, and the application 
of warm water and of the vinum opii only to the eyes, 
are the most generally effectual means in the strumous 
ophthalmia. 

In the Iritis, after loss of blood, Mercury is by far the 
most important remedy, and when its constitutional ef- 
fect is produced, both the inflammation and attending 
pain, and the effusion on the iris, if already effected^ are 
generally observed to abate almost immediately ; and 
this not only in the syphilitic but idiopathic cases. The 
extract of Belladonna applied to the eye or forehead, so 
as to cause and keep up dilatation of the pupil, is here 
likewise useful. 

In the latter stages of all the forms, but especially of 
the strumous ophthalmia, when much tenderness of the 
eyes continues, or when there are ulcers on the cornea, 
much benefit may often be derived from some parts of 
the tonic regimen, particularly a fuller diet, country air, 
and gentle exercise. In such cases also, local astrin- 
gents, as the solution of nitrate of silver carefully ap- 
plied to the ulcers, often relieve the inflamrnation more 
than any general remedies. 



Sect. IV. — Of Inflammation of the Ear. 

This inflammation demands attention chiefly on ac- 
count of its tendency, both in the acute and chronic form, 



INFLAMMATIONS OF THE NERVOUS SYSTEM, &€, 357- 

to pass inwards to the internal ear, and thence through 
its thin osseous covering to the Dura Mater and Brain. 
^ It occurs most frequently, by no means only, in chil- 
dren, and especially in those of scrofulous habit, and 
is known by pain, often very severe, in the ear, with tin- 
nitus, impatience of sound at first, and afterwards deaf- 
ness, and usually, after a few days, is attended with se- 
rous and puriform discharge from the ear. It is some- 
times brought on simply by cold, or occurs without ob- 
vious cause ; but very often is connected with some form 
of cutaneous inflammation ; and often occurs as a sequela 
of febrile disease, sometimes in connection with sore 
throat, apparently by extension of the inflammation 
along the Eustachian tubes. 

In acute cases, the violence of the pain, especially its 
shooting through the head, and the intensity of fever, 
— especially if attended with vomiting, — ^give most 
ground for apprehension of the inflammation extending 
inwards ; in chronic cases, and scrofulous habits, it may 
do so more insidiously, but seldom without such threat- 
enings of the symptoms of inflammation of the brain, 
as may excite suspicion. 

Even when not affecting the brain, it may often cause 
erosion of the membrane of the tympanum, — often dis- 
charge of the small bones, and not unfrequently caries 
of some part of the temporal bone, particularly of the 
mastoid cells. In such cases an external abscess 
usually forms in connection with it ; and the facial 
nerve is often palsied. 

In the early stage, it ought to be treated by leeching, 
purging, and the antiphlogistic regimen, warm fomenta- 
tions, poultices, and anodyne applications ; but imme- 
diately on a sudden increase of the pain, extendino- 



358 OUTLINES OF PATHOLOGY AND PRACTICE. 



through the head, with febrile symptoms, it should be 
met, in children above the age of five, or adults, by 
general bloodletting, which must sometimes, in adults, 
be carried to a great length before the symptoms are 
relieved. 

In the chronic state, warm fomentations, protection 
from cold, keeping the bow^els open, and careful watch- 
ing for more acute symptoms, are the chief means to be 
employed ; and the most important practical rule is, to 
be very cautious about the use of astringent applica- 
tions, — suppression of the discharge having often been 
followed by an extension of the inflammation of the 
dura mater and brain. 



( 359 ) 



CHAPTER VI. 

OF INFLAMMATIONS OF THE ORGANS OF LOCOMOTION 
AND SUPPORT. 

We place tlie inflammations of the voluntary Mus- 
cles and appendages, and of tlie Bones, Ligaments, Sy- 
novial, and Fibrous members together, as occurring very 
frequently in connection with each other, and obviously 
distinct from those of the viscera hitherto considered. 

Sect. I.- — Of the Rheumatism, 

The peculiar kind of Inflammation which was no- 
ticed under this title (p. 182), occurs in two well known 
forms (graduating into one another, by insensible de- 
grees), the Acute and Chronic, and is very generally 
immediately excited by cold, particularly applied after 
heat, although there is no doubt some previous pe- 
culiarity in the constitution, which disposes certain in- 
dividuals to be affected in this way ; and the tendency of 
the disease to affect so many distinct parts indiscrimi- 
nately in quick succession, and the recent observation 
of the existence of Lithic Acid in effusions from rheu- 
matic as well as gouty inflammation^, may lead us to 
suspect that this peculiarity consists in the constitution 
of the blood.* 

* See M'Leod on Rheumatism. 



360 OUTLINES OF PATHOLOGY AND PRACTICE. 



The Acute form of Rheumatism occurs chiefly in 
yomig persons, often in vigorous and plethoric habits, 
and is often attended with much fever, and very intense 
pain, aggravated by heat, especially at nights, and by 
any attempt at motion. Its violence may be much mi- 
tigated by treatment ; but the duration of a well mark- 
ed case is seldom less than six weeks, often, particularly 
in winter, it is protracted considerably longer ; or if it 
abate sooner, a relapse is extremely probable. It 
usually affects some of the larger joints, in quick suc- 
cession, and likewise muscular parts ; and a distinction 
may be drawn, in many cases, as it affects the one or 
the other chiefly, between the Articular and the Mus- 
cular Rheumatism. In the joints it leads at first al- 
ways to fluid effusion, sometimes mixed with lymph, 
(probably never, in truly rheumatic cases, with pus), 
on the synovial membrane, which, however, seldom be- 
comes so great, in the course of the rheumatic fever, as 
when inflammation attacks single joints, and is fixed 
there for a long time. In cases of some duration, 
thickening of the synovial membranes and ligaments, 
and sometimes enlargements of the ends of the bones, 
are to be expected. Similar changes take place in the 
fasciae and sheaths of the muscles from rheumatic in- 
flammation; and when that is of long standing, it 
causes permanent weakness, and more or less of atro- 
phy of the muscular fibres, but it seems rarely to lead 
to softening of the muscular fibres, and probably never, 
when uncomplicated, to suppuration in any part of the 
body. 

There are many cases of the disease, to which the 
term Sub-Acute is properly applied, attended with some 
degree of fever, and often slight swelling, and with 
severe pain, aggravated at nights, but without the high 



INFLAMMATIONS OF ORGAN.S OF LOCOMOTION, &C. 361 



fever, intense pain, or frequent successive affection of 
different parts, of the acute disease. In several of these, 
the affection is limited for a considerable time to in- 
dividual parts. This is seen often in one knee or one 
shoulder ; in one side, causing the Pleurodyne ; in the 
loins, causing Lumbago ; in the hip-joint, causing Scia- 
tica ; in the temple, or side of the head, causing Hemi- 
crania. In the two last cases, the nerves of the part 
may be often judged to be the chief seat of the pain, 
and the disease graduates into Neuralgia. 

In women, more frequently than in men, the Acute 
or Sub- Acute Rheumatism, lasting longer than usual, 
leads often to permanent enlargement and distortion of 
the ends of the bones, causing Nodosity of the Joints, 
chiefly seen in the smaller joints (where it has been 
often called Rheumatic Gout), but sometimes also in 
the larger. 

The strictly Chronic Rheumatism occurs in all the 
same parts as the Acute, and is distinguished by the 
absence of fever, and generally by swelling (the mus- 
cular parts being often much wasted), by the pain being- 
aggravated by cold, and relieved by heat, and attended 
with much stiffness, and often coldness of the affected 
parts, and by its long and indefinite duration. 

The Sub- Acute and Chronic forms of the disease are 
remarkably aggravated or renewed by cold, especially 
when combined with moisture, and may always be ex- 
pected to abate greatly during the summer weather of 
this climate. 

The disease, although often producing much suffer- 
hig, and weakening the habit of body, is hardly ever at- 
tended with danger, excepting in the case, unfortunately 
not uncommon, of metastasis or extension of the in- 



362 



OUTLINES OF PATHOLOGY AND PRACTICE. 



flammation to the heart, most commonly to the Peri- 
cardium, but frequently to the internal lining membrane, 
where it produces the symptoms and consequences of 
Pericarditis and Endocarditis, already stated. This is 
more frequently seen in the rheumatism of young than 
of older persons, and especially in those who have a 
peculiar liability to the disease, in whom it is probably 
most frequent in the second or third attack of the acute 
disease. The case of complete recession of the inflam- 
mation on the extremities, and sudden affection of the 
heart, is more immediately dangerous than that where 
the heart is affected more gradually and insidiously, in 
the course of transition of the disease from one part to 
another, without leaving the extremities. 

The Acute Rheumatism cannot, probably, be much 
shortened in its duration by antiphlogistic remedies, and 
if it were so shortened in external parts, we have good 
reason to think that the risk of affection of the heart 
would be greatly increased. For although the transla- 
tion to the heart has been observed to take place under all 
modes of treatment of the disease, yet it has been seen to 
follow large bleeding, and immediately consequent reces- 
sion of the inflammation on the extremities, often enough 
and quickly enough to justify much apprehension of such 
a result, when the quantity of blood taken is so great as 
to produce a marked and immediate effect on the heart's 
actions. The general bleeding in the beginning of the 
disease should therefore only be employed^ as Cullen 
advised, to the extent of taking off or diminishing the 
phlogistic diathesis ; where there is a rather feeble pulse 
it may often be dispensed with ; and local bleedings are 
of little use in the strictly acute form, unless the inflam- 
mation be fixed much longer than usual in a particular 



INFLAMMATIONS OF ORGANS OF LOCOMOTION, &C. 363 

joint. In most cases, however, one or two bleedings in the 
beginning, give much reHef to the feelings, and obviously 
assist the effect of other remedies. Regular evacuation 
of the bowels is essentially necessary, and in some cases 
the full effect of purgatives seems distinctly beneficial, 
but frequently this only causes inconvenience. 

In the view of further mitigating the violence of the 
disease, and probably often preventing its passing into 
an obstinate chronic form, the most important remedies 
are, — 

1. The Antimonial Solution, given in the manner 
stated under the head of Pneumonia. 

2. The Colchicum in powder, or in various solutions, 
in doses which cause slight nausea, repeated every four 
or six hours. 

3. The Sudorifics, particularly Dover's Powder, with 
the sudorific regimen, so managed as to cause pretty 
copious sweating for thirty-six hours or longer. The 
saline diaphoretics are usually given at the same time 
with these medicines, and probably somewhat assist their 
operation. 

It seems to be owing to peculiarity of constitution, 
that each of these remedies appears to be more distinctly 
eflPectual in some cases than in others ; but none of these 
should be carried so far as to cause much weakness, as 
may be apprehended from the nauseating effect of anti- 
mony, or the purgative effect of colchicum, or the de- 
pressing effect of profuse sweating. 

Along with the measures stated, the regular use of 
opiates, particularly of the preparations of Morphia, 
at night or oftener, is certainly advisable, and some re- 
lief is given by the opiate fomentations or frictions. 

No reliance whatever can be placed on the specific 



364 OUTLINES OF PATHOLOGY AND PRACTICE. 



power of Mercury over tliis inflammation ; and the full 
effect of mercury on the system during the disease may 
in many persons be injurious. 

When the disease is in the subacute form, and limited 
to single parts, or remains in single parts after subsiding 
elsewhere, local bleedings and bhsters have often singu- 
lar efficacy in relieving it. The Sciatica, however, is 
the form of the disease over which these remedies have 
generally the least power. 

" When the exacerbations of the disease are manifestly 
periodical, with considerable remissions interposed," 
Bark or the Sulphate of Quinine, in frequent doses in 
the intervals, is certainly very useful ; but its peculiar 
utility seems to be confined (as long ago stated by Cul- 
len) to cases of this kind. 

In this, however, as in other inflammations, after the 
general fever has abated, but while some of the local 
symptoms continue, a relaxation of the antiphlogistic 
regimen, and the use of bitters and acids, particularly if 
there be, as often happens, much sweating, becomes use- 
ful, and in these circumstances the Quinine has often a 
good efi*ect on the general health. 

In the Chronic Hheumatism a great variety of medi- 
cines have been used, each of which has apparently a 
certain degree of power ; but many cases resist all re- 
medies, and either continue more or less for life, or abate 
spontaneously, particularly during fine weather, when 
no remedies are employed. Those most generally use- 
ful are, 

1. The Sudorifics, used repeatedly, but not too long 
continued at one time. 

2. The frequent use of the warm-bath, warm affiisions, 
anithe vapour-bath ; likewise the sulphur vapour-bath. 



INFLAMMATIONS OF ORGANS OF LOCOMOTION, &C. 365 



These, however, must be discontmued if it be found, 
after a time, that there is much sweating without relief 
to the pains. The natural warm springs appear fre- 
quently more effectual than the use of water a^rtificially 
heated, probably because admitting and inviting the use 
of a more truly tonic regimen along with them. 

3. Constant warm clothing, the use of flannel and 
Chamois leather. 

4. Frictions, with various stimulating and anodyne 
Embrocations, which promote the circulation in the af- 
fected limbs. 

5. Difi'erent kinds of Counter-Irritation, repeated 
blistering in cases which take the subacute form ; and 
in those where the pain is fixed long in one part, as in 
Sciatica, a more permanent drain by an issue, or the 
moxa ; in some such cases approaching to neuralgia, 
also the Acupuncture has been distinctly useful, and in 
others the Galvanic stream. 

6. The Vegetable diaphoretics, Sarsaparilla, Guaiac, 
&c. 

7. Various medicines called Alteratives, because the 
mode of their action is uncertain. Thus Arsenic, in 
small doses, taken for a considerable time, has seemed 
useful to some, and the Hydriodate of Potass to a greater 
number, especially when the periosteum has been affected. 

8. When the strength is tolerably entire, tepid or even 
cold bathing, during good weather, is often more useful 
than warm, no doubt because it is more effectual in sti- 
mulating and maintaining a vigorous circulation on the 
surface, and relieving internal parts. 

9. Opiates must be given, sometimes in full quantity, 
when the pains are urgent, but may often be dispensed 
with when the pains are least felt at night ; and neither 



366 OUTLINES OF PATHOLOGY AND PRACTICE. 



these nor any otlier remedy should be urged when it 
shall appear to injure the stomach and general health. 

10. In the perfectly chronic state, and in a constitu^ 
tion originally good, much exercise, even such as causes 
much sweating and temporary increase of pain, is some- 
times followed by decided remission of the symptoms. 

Sect. 11.— Of the Gout. 

The very peculiar form of inflammation to which this 
name is given attacks only a certain portion of mankind, 
men much more than women, seldom before middle life, 
most frequently those who have a hereditary tendency 
to it ; and almost exclusively those who have lived fully, 
taken little exercise, and much fermented liquors. Its 
attacks are therefore probably much connected with ful- 
ness of blood ; but that there must be some peculiarity 
in the chemical constitution of the blood in this disease, 
appears most clearly, not only from the peculiarity of 
the deposition from the inflamed parts formerly noticed, 
but from the fact, that those who drink only distilled 
spirits, although living in other respects as similarly as 
possible, and although becoming plethoric, are affected 
in a proportion very much less than those who drink 
fermented liquors. On the other hand, those who drink 
fermented liquors to excess, as the London coalheavers, 
although in other respects, particularly as regards exer- 
cise, in circumstances generally favourable to avoiding 
the disease, are frequently affected by it. But we can- 
not doubt that the elaboration of the peculiar matter 
which we believe to exist in the blood in this disease, is 
dependent, not merely on the nature of the ingesta, but 
on the vital actions to which they are subjected. 

7 



INFLAMMATIONS OF OEGANS OF LOCOMOTION, &C. 367 

In those predisposed by fulness of blood, by original 
constitution, and by tbe mode of life above stated, the 
disease is most generally immediately preceded by feel- 
ings of weakness and anorexia, sickness, acidity, pain or 
flatulence at stomach, — ^often traced either to errors in 
diet or venereal excesses. It seems to be often brought 
on by sprains or injuries, comparatively seldom by 
cold. 

The first attack of the inflammation is very generally 
after the first sleep, when the other efl'ects of fulness 
of blood are also chiefly observed, and the part first af- 
fected is generally at the very extremity of the circula- 
tion. When running its natural course, the inflammation 
usually continues some days, with morning remissions, 
at this part, and afl'ects others before finally subsiding. 
The next attacks are at long intervals ; but the disease is 
very apt to become habitual, and then to recur at shorter 
intervals, and from slighter causes, — to attack a variety 
of parts and especially larger joints, — often to leave 
concretions or chalk-stones, which lead to troublesome 
ulcers, and abate less completely, — and to become com- 
plicated with more permanent dyspepsia, and with vari- 
ous other complaints. It is very generally observed, in 
the paroxysms of the disease, that the urine is more 
loaded both with urea and the lithates than is usual ; 
and it is known that a large proportion of those who 
are subject to Gravel are likewise Gouty ; yet it is equally 
certain that many cases of each disease are quite uncon- 
nected with the other. 

Two peculiarities have particularly been observed in 
such persons. 1. That sudden recession of the gouty' 
inflammation in the extremities has often been quickly 
followed by violent pain at stomach, with sinking of the 
circulation, constituting the Retrocedent Gout, 2, That 



368 OUTLINES OF PATHOLOGY AND PRACTICE. 



sudden and violent internal inflammatory attacks, chiefly 
in the chest (sometimes complicated with Spasm), have 
often been observed in such persons, and found to alter- 
nate with the Gout in the extremities. Such cases have 
the name of Podagra aberrans, or misplaced Gout. 

The knowledge of these facts has naturally led to a 
general unwillingness to interfere with the progress of the 
disease, farther than by the antiphlogistic regimen, and 
the mildest antiphlogistic remedies, at the time of the 
paroxysm ; and to the use of various medicines during 
the intervals, to diminish the tendency to the disease. 

Experience has however shewn, that although full 
bleeding and purging in the paroxysms of gout are at- 
tended with risk, yet by moderate evacuations, and espe- 
cially by repeated doses of Colchicum, with antacids (or 
of different empirical medicines, the effects of which 
seem similar to those of Colchicum), many fits of the 
disease may be very much mitigated and shortened, 
without injury to the constitution, if the treatment dur- 
ing the intervals is judicious. The chief practical caution 
as to these medicines is, that if carried too far they 
cause excessive sickness, purging, and faintness, demand- 
ing stimulants and opiates. 

But experience has also shewn, that neither by reme- 
dies used during the paroxysms, nor by any means, — 
such as various bitters and aromatics used during the 
intervals, and said to have this effect, — is it desirable to i 
stop the fits of Gout and prevent their recurrence, while I 
the same mode of life which led to their formation is ! 
continued ; various internal diseases, chiefly of the chest I 
or head, having then frequently taken their place. ,j 

But while the paroxysms are mitigated in the manner !j 
above stated, if at the same time a regimen is adopted, \ 
which gradually diminishes the tendency to the disease, ; 

8 



INFLAMMATIONS OF ORGANS OF LOCOMOTION, &C. 369 



the liealtli of persons beginning to be thus affected may 
often be satisfactorily restored. 

Such a regimen must consist essentially of a diet 
chiefly vegetable, which shall not favour fulness of 
blood nor offend or oppress the stomach, with great mo- 
deration, — in some persons total abstinence, — as to 
strong liquors, and much habitual exercise, and other 
parts of the general tonic plan. Along with these, ant- 
acids, laxatives, and bitters, taken habitually for a great 
length of time, appear decidedly useful in warding off 
attacks of Gout ; but whether they are so merely by 
preventing disorder at stomach, and consequent occa- 
sional weakness, or more directly by correcting the pro- 
cess of assimilation and modifying the nature of the 
blood, is still doubtful. 

When the symptoms either of the retrocedent or mis- 
placed Gout shew themselves, they must be treated as 
in persons not gouty, but with peculiar care and atten- 
tion, on account of the sudden attacks both of inflam- 
matory and of spasmodic or (more correctly) neuralgic 
complaints to which such persons are liable. 

Sect. 111.— Of Inflammations of the Periosteum^ Bones^ 
and Joints, 

Cases of acute and healthy inflammation of these 
parts seldom occur, unless when caused by injuries, — - 
with the exception of inflammations of the Synovial 
membrane of joints, or of Bursse Mucosae in the neigh- 
bourhood of joints, which not unfrequently occur from 
cold, or from slight mechanical injury, with only slight 
rheumatic affection of other parts. These are in ge- 

2 A 



370 OUTLIxNES OF PATHOLOGY AND PRACTICE. 

iieral easily distinguished by pain and swelling attacking 
simultaneously, and by the rapid distention of the joint 
by a fluid, which becomes obvious on careful inspection 
from the form and feeling of the swelling, and may 
in general be effectually relieved by absolute rest, re- 
peated local bleedings (which must sometim.es be car- 
ried to a great length), fomentations, and subsequently 
blisters, — often leaving behind them, however, thicken- 
ing of the Synovial membrane and stiffness of the joints, 
admitting of subsequent relief from warm affusions and 
stimulating frictions. 

It is probably almost exclusively in the case of in- 
flammation of a vein, and secondary affection of the 
joints, that effusion of pus on the entire Synovial mem- 
brane ever takes place ; but Vv^hen that inflammation is 
, neglected, or lasts longer than usual, especially if the 
constitution is scrofulous, exudations on the membrane 
ultimately pouring out pus, and ulceration of the carti- 
lages, to be mentioned immediately, are to be appre- 
hended. 

Acute inflammation of the Periosteum occurs occa- 
sionally, particularly in young persons, probably oftener 
in scrofulous than sound constitutions ; generally in 
combination either with symptoms resembling Rheuma- 
tism, or with Ery thematic inflammation of the skin ; 
which make its recognition in the early stage difficult ; 
but it may be suspected from the seat and violence of the 
pain, and acute febrile symptoms. If not checked by 
early antiphlogistic treatment, the probability is, that 
it will lead to effusion of pus, often extensive, between 
the Periosteum and bone, and to consequent death and 
exfoliation, or in some instances, complete disorganiza- 
tion and softening, of the bone ; with which abscesses 



INFLAMMATIONS OF ORGANS OF LOCOMOTION, &C. 371 



of the neighbouring soft parts are usually combined. 
If the swelling and tenderness along the bone can be 
distinctly perceived, and the general symptoms are so 
acute as to lead us to expect these consequences, and if 
the antiphlogistic treatment shall not be commenced 
early enough, or carried far enough, to arrest those ter- 
minations, the farther progress of the disease may 
sometimes be effectually arrested by incisions down to 
the bone, giving exit to purulent matter there effused, 
and limiting the extent of exfoliation ; of this we have 
an example in the most severe form of Paronychia. 

We see the Periostitis much more frequently in a 
sub-acute or chronic form, causing painful nodes usually 
on the cranium, on the sternum, or long bones of the 
extremities, most frequently in persons who have had 
Syphilis, or been affected with mercury, or both ; but 
occasionally in persons who have suffered from neither 
of these causes. These are attended with very severe 
pains, chiefly in the night, and frequently go on, espe- 
cially in scrofulous constitutions, to partial caries, 
and, when affecting the cranium, sometimes to inflam- 
mation of the dura mater, — effusion of pus there, — and 
abscesses in the neighbouring portions of brain ; but 
they often abate completely under repeated local bleed- 
ing, blisters, opiates, and the persevering use either of 
the Sarsaparilla, or Hydriodate of Potass. 

It is also certain, that in some of these persons, mer- 
cury given so as to affect the system, has been followed 
by rapid improvement of the disease ; and when it is un- 
usually rapid in its progress, particularly on the cranium, 
it is therefore often right to use this remedy, after such 
evacuations, as the febrile symptoms may seem to de- 
mand ; but with these cautions,— ^/i?^^, that there are 



372 OUTLINES OF PATHOLOGY AND PRACTICE. 

some persons in whom no sucli beneficial effects are 
seen from it, and in whom perseverance in its use may 
be injurious in different ways ; and, secondly^ that even 
in those in whom it has seemed decidedly beneficial, the 
disease has often been observed to return, or appear at 
another part, very soon after it has been used ; or other 
symptoms, partly referable to the effect of the mercury, 
especially various forms of scrofulous disease, have 
shewn themselves. It may be stated, therefore, that 
this remedy should only be used when we are sure of 
adherence to verv cautious reoimen, both durino- and 
after its use ; and that we can generally rely on the 
permanence of any improvement that may be eff'ected 
without the use of mercury, and especially by such re- 
medies as Sarsaparilla and Hydriodate of Potass, under 
which the appetite very often improves, more than on 
such as is effected by its aid. 

When the tendency to this chronic inflammation of 
the Periosteum and Bones is obstinate, a course of 
warm bathing, — free exposure to the open air in mild 
and dry weather, and such a tonic regimen as is adopted 
at the different natural hot springs and watering-places, 
become often very useful. 

There are cases of Chronic Rheumatism and Perios- 
titis, in persons previously healthy, in which the extre- 
mities of the bones become gi'adually enlarged and dis- 
torted, causing permanent lameness or immobility, in 
some instances even anchylosis, by very gradual perver- 
sion of nutrition of the Bones and Cartilages, and in 
w^hich the body is gradually reduced to a state of hope- 
less debility and emaciation. 

But the case of chronic disease of these textures 
themselves, commengjing, or occasionally combined,. 



INFLAMMATIONS OF ORGANS OF LOCOMOTION, &c. 373 



with inflammation, which most frequently occurs in 
practice, is the scrofulous affection, admitting of some 
variety in its course, but commencing generally by in- 
flammation of chronic character, going on to ulceration 
of the cartilages, and to efl'usion of tubercular matter, 
and then to caries in the bones, of which the Morbus 
Coxarius, and the Morbus Dorsalis, are characteristic 
examples, both occurring chiefly in children and young 
persons of scrofulous parents and habit. 

It would appear that when the articular cartilages are 
aff'ected with this inflammation, and about to ulcerate, 
there is more pain than from disease commencing in the 
osseous matter. The pain is felt chiefly in the night, 
and for some time before any swelling or change of form 
shews itself ; and is distinctly aggravated by pressing 
the ends of the bones against one another. The Morbus 
Coxarius is almost always easily known by this mark, 
and by the change afterwards gradually supervening on 
the form of the hip-joint — the nates becoming flatter 
and broader than on the other side — the limb being at 
first apparently longer than the other, in consequence of 
the pelvis becoming oblique by the patient instinctively 
resting on the sound limb, — and afterwards becoming 
truly shorter, by the absorption of part of the head of 
the bone, and often likewise by the diminished nutrition 
consequent on the limb being long kept at rest. 

When scrofulous inflammation and tubercular deposi- 
tion take place originally in the cancelli at the extremi- 
ties of the long bones {e. g. at the knee or elbow-joint), 
there is comparatively little pain, until the form of the 
joint or bone has undergone much change, chiefly by 
enlargement of those extremities ; but by this change of 
form, confined at first to the bones, such cases may in 



374 



OUTLINES OF PATHOLOGY AND PRACTICE. 



general be distinguislied from those swellings, likewise 
witliout pain, but of softer consistence, and altering en- 
tirely tbe form of the joint, in which the disease seems 
to depend essentially on a perversion of nutrition, with- 
out previous inflammation, of the synovial membrane or 
capsular ligament, and to which the name White Swell- 
ing is most properly restricted. 

The Morbus Dorsalis is easily distinguished, soon 
after its commencement, by the protrusion of the spinous 
processes of those vertebree of which the bodies have 
become softened by the scrofulous inflammation, which 
is always attended by deposition of soft lymph, or of tu- 
bercular matter, and by absorption of the earthy matter ; 
and goes on ultimately to much destruction, by ulcerative 
absorption of the bodies of the vertebrae, and union by 
anchylosis of several of the bodies, thus greatly reduced 
in size. 

These inflammations and scrofulous actions in bones 
and cartilages are always sooner or later attended by 
chronic inflammation, going to suppuration, of the ad- 
joining soft parts ; but in some cases these suppurations 
take place more rapidly and extensively, or at a greater 
distance from the afi*ected bone, than in others, as in the 
most severe cases of Lumbar Abscess, connected with 
disease of the vertebrae. 

All these affections, if remedies earlv used are ineffec- 
tual in checking them, must be expected to become at- 
tended with wasting and exhausting hectic fever. The 
Morbus Dorsalis is likewise very often attended with 
Paraplegia, depending not simply on the pressure of the 
diseased bone on the spinal cord, but generally on ex- 
tension of inflammation, and consequent softening of the 
nervous matter. 



INFLAMMATIONS OF OEGANS OF LOCOMOTION, &C. 375 

The affection of the bones in Rickets is likewise to be 
regarded as a scrofulous affection ; but it is a perversion 
of nutrition, unconnected with inflammation, general 
over the body, and easily distinguished from the partial 
and painful affection of the bones in the Morbus Dorsalis, 

The lateral curve of the Spine is likewise easily dis- 
tinguished from the Morbus Dorsalis, and found to de- 
pend on weakness and imperfect nutrition of the parts, 
but to be unconnected with inflammation, and often 
likewise unconnected with scrofulous disease. 

For the local, scrofulous, and often inflammatory af- 
fections of bones and cartilages above mentioned, local 
bleedings in the commencement are sometimes useful, 
but the state of the constitution, and known slow pro- 
gress of the disease to be expected, generally make it 
desirable to avoid much loss of blood ; and the most 
important remedies for them are the Counter-irritants, 
especially Issues or Setons, which give a full discharge. 
During their use, the diet should be nourishing, and 
such parts of the Tonic Hegimen as are admissible with- 
out exercise, and in a feeble habit, particularly fresh air 
and moderate mental excitement, are very important ; 
but rest of the part affected, and, when it is the spine, 
the recumbent posture, are necessary for a great length 
of time. In the advanced stage, however, the constitu- 
tion suffers from confinement, and it becomes often 
advisable, after the counter- irritation has taken some 
effect on the disease, to adopt some such mode of ex- 
ercise as may give least irritation to the affected part, 
even at the risk of some aggravation of the local symp- 
toms. And it is by taking off the pressure of the body 
in the erect posture, from the affected vertebrae, and 
throwing it on the lower vertebree which are sound, that 



376 OUTLINES OF PATHOLOGY AND PRACTICE. 



meclianical supports enable patients in the Morbus Dor- 
salis to take exercise without the aggravation which 
would otherwise result from it, and are chiefly useful. 

The scrofulous diseases of the bones, and inflamma- 
tion of neighbouring parts, often last long, and go to 
partial caries in the elbow and forearm, and admit of 
gradual and nearly spontaneous cure, when the strength 
of the constitution is well maintained ; but the hectic 
fever attending such disease in the lower extremities, 
hip-joint, or spine, is often fatal. In those cases where 
amputation of a limb is resolved on as the best chance 
of preventing that termination, it is most important to 
keep in mind the fact stated as to deposits of purulent 
matter taking place in internal parts soon after an ex- 
tensive suppurating surface has been removed ; and the 
risk of this is probably diminished by such treatment of 
the stump as secures a free discharge from its surface 
for a considerable time. 



( 377 ) 



CHAPTER VII. 

OF INFLAMMATIONS OF THE INTEGUMENTS. 

Reserving for future consideration the true Exan- 
themata, or strictly eruptive Fevers (among which we 
include Erysipelas), and omitting those inflammations of 
the skin, which result immediately from injury, burn, 
or frostbite, — we have still a greater variety of diseased 
states of the integuments, originating in inflammatory 
action, than we believe to exist in any internal part. 
The classification of these by Willan, founded on the 
kind of effect which the inflammation produces in each, 
is generally allowed to be, so far as the distinction of the 
inflamed appearances in the skin is concerned, the 
most scientific ; and the chief distinctions which he has 
drawn may be generally recognised, when the diseases 
are seen from their commencement and follow their 
usual course ; but these distinctions are more numerous 
than can be generally and accurately observed ; and 
much of the most important practice in these com- 
plaints is regulated by the state of the symptoms in 
other respects, — the kind and degree of fever or inflam- 
mation, the state of the stomach, &c., — more than by 
the distinctive marks of the eruptions. 

The most important distinctions among the inflamma- 



378 OUTLINES OF PATHOLOGY AND PRACTICE. 



tions, acute and chronic, to which the skin is subject, are 
the following. 

1. An inflammation of the character called Ery the- 
matic (p. 178) not only occurs in connection with a 
peculiar fever, in the cases properly called Erysipelas, 
when the febrile symptoms are established before an 
inflammation shews itself ; but is often excited by the 
usual causes of inflammation, acting on particular consti- 
tutions, and especially on certain parts of the body, as 
the skin of the face and scalp ; and in such cases fever 
appears generally only as an eflect of the inflammation 
which has been excited. 

Such Ery thematic inflammation extends rapidly over 
a considerable part of the skin, causing often vesica- 
tions on the surface ; and likewise extends inwards in 
many cases, so as to afl*ect the cellular substance, 
and lead either to a diff'use purulent infiltration of this 
texture, or to the formation of tolerably distinct ab- 
scesses bounded by lymph ; or in a few cases of slower 
progress, to great efl*usion of more solid lymph, which 
does not tend to suppuration, and is slowly and im- 
perfectly reabsorbed, producing permanent enlargement 
of the limb. The observations of Dr Duncan and others 
have shewn that a Difliise Inflammation of the subcuta- 
neous, sometimes extending to the intermuscular cellu- 
lar membrane, tending to purulent eff'usion, without limi- 
tation by coagulable lymph, occurs frequently, and at 
times epidemically, in connection with Ery thematic in- 
flammation, but often extends farther than the disease 
on the skin, and sometimes takes place without any cu- 
taneous aflection ; that this diff'use inflammation fre- 
quently proceeds from a morbific poison, such as that 
introduced by a wound in dissection, or that which is 



INFLAMMATIONS OF THE INTEGUMENTS. 



379 



generated in the suppuration succeeding Ery thematic 
inflammation itself ; but that in some cases it seems to 
result from the usual causes of inflammation ; that when 
it proceeds from a poisoned wound, it sometimes spreads 
gradually up the veins or lymphatics of the part, but 
often, and in the worst cases, afffects the cellular mem- 
brane in a distant part [e. g, the axilla) without spread- 
ing along the surface towards it ; that inflammation of 
the lymphatic glands is not observed in many of those 
most unfavourable cases ; and that the fever attending 
such inflammation is exceedingly various, both in kind 
and intensity, often typhoid, and demands therefore 
much diflerence in the general treatment of difi'erent in- 
dividual cases. 

Some cases of cutaneous inflammation, attended with 
more or less of symptomatic fever, are more circum- 
scribed in their extent, never aff'ect the sub-cutaneous 
membrane, nor go to vesication, but run a pretty uni- 
form course on the skin of many days' duration, chang- 
ing colour remarkably to livid or rust colour before they 
subside ; — such are the Erythema papulatum and nodo- 
sum, the latter of which is chiefly seen in women in 
connection with deficient menstruation. 

The simple rose-coloured rash on the skin, generally 
combined with other cutaneous diseases, to which the 
name of Roseola is given, and the itchy eruption of in- 
flamed spots, with whitish elevations on them, called 
Urticaria, — which occurs both in the acute and chronic 
form, the former almost always from some poisonous 
article of diet, and usually abates and recurs repeat- 
edly,— are also examples of inflammation occurring on 
the skin, sometimes attended with much fever, but 
with so little of the characteristic efl*usions, as almost to 



380 OUTLINES OF PATHOLOGY AND PRACTICE. 



afford exceptions to the general principle stated, of such 
effusions being essential to inflammation. The same 
may be stated as to what are strictly called papular 
eruptions or pimples, which very seldom contain a fluid, 
and terminate only in scurf — such as the Strophulus of 
young children, and the Lichen and Prurigo of adults. 
In all these, however, a little inflammatory effusion 
shews itself in the scurf that succeeds the affection. 

2. There are many cases of Inflammation of the 
Skin and sub-cutaneous cellular membrane, which have 
the character of Phlegmon, because going regularly to 
suppuration ; but of these also there is much variety. 
Abscesses, acute and chronic, form immediately beneath 
the skin, in various parts, — often without obvious cause, 
— sometimes apparently from stimulation of the body, 
as by violent exercise. In certain constitutions, gene- 
rally weak and irritable habits, the form of phlegmonous 
inflammation, called Carbuncle, takes place, distin- 
guished by its slow progress, by the cellular substance 
beneath the inflamed part of the skin, being much 
hardened, and forming always a number of minute cells, 
into which the pus exudes, and by this diseased part of 
the cellular membrane uniformly sloughing, and re- 
quiring therefore incision, not merely puncture, for the 
thorouo'h evacuation of the matter. 

Another form of inflammation of the skin, tending 
more certainly and rapidly to Gangrene, and almost 
uniformly fatal, but otherwise resembling the Carbuncle, 
is that which results from the poison of Glanders, in 
any way applied to the human body, and which is at- 
tended with a deposition of peculiar Tubercles, in va- 
rious external parts of the body ; similar to those in 
which the disease originates in the horse. 

When the suppurating portions of the skin are more 



INFLAMMATIONS OF THE INTEGUMENTS. 381 



numerous and smaller, we have the affections, to which 
the names Ecthyma and Impetigo are applied, accord- 
ing as the pustules formed are more circular and acu- 
minated, or flat and irregular, or we may have the con- 
tagious diseases, Scabies or Porrigo, the course of all 
which is exceedingly irregular, and generally protracted. 

Some of those often chronic affections of the skin, to 
which the name of Tubercles is given by Willan, espe- 
cially the Acne and the Sycosis, are also examples of 
pustular inflammation, with partial suppuration. 

3. Again, there are many well marked cases of idio- 
pathic inflammation of the skin, which go to vesication 
or effusion of serum only beneath the cuticle, not to 
suppuration ; of these the best marked examples are, 
the Herpes, as in the case of the H. Zoster, or shingles, 
occurring chiefly in young persons, consisting of many 
small vesicles, set on a single inflamed base, running its 
course in a week or ten days, — and the Eczema, occur- 
ring chiefly in persons advanced in life, and of feeble 
general health, where the vesicles are much more 
minute, and the progress of the disease much longer, 
and more indefinite. 

The large vesicles of Pemphigus, and the broad flat 
patches of Rupia, afterwards going to ulceration, or to 
the formation of large conical scabs, are other instances 
of vesicular cutaneous inflammations. 

4. A still more distinctly marked variety of the cu- 
taneous inflammation, is the Lepra or Psoriasis, and here 
the peculiarity consists in the exudation on the surface 
being always dry and scaly. This kind of inflamma- 
tion occurs in a certain habit of body only, which is 
sometimes hereditary, but which is often attended with 
good health in other respects ; and it is excited at va- 



382 OUTLINES OF PATHOLOGY AND PRACTICE. 



rious periods of life, perhaps especially during youth, 
by various causes, — especially cold, or irritation and 
disorder of the stomach, — and often occurs without ob- 
vious cause, — abates spontaneously after very various 
periods, but is very apt to recur. The state called Ich- 
thyosis, usually likewise a hereditary affection, is that in 
which the most completely scaly condition of the skin 
exists, but as a constitutional perversion of nutrition, at 
no time inflammatory. 

It is farther to be observed, that the Syphilitic poison, 
varying continually in its action^ either according to va- 
rieties of its own nature, or to peculiarities of constitu- 
tion of the persons affected, or to both, excites several 
kinds of inflammation on the skin, generally resembling 
the Lepra, the Ecthyma, Impetigo or Rupia, and fre- 
quently going along with the syphilitic inflammation 
and ulceration of the throat, occasionally also with that of 
the Iris; and again, that in certain, although rare con- 
stitutions. Mercury acts as a cause of a more uniform 
cutaneous inflammation, of the nature of that to which 
the name of Eczema is applied, and which is often ex- 
tremely obstinate. 

All the forms of Chronic inflammation of the skin 
are of common occurrence, and very often cause long- 
continued sufferings ; and in a few cases, of unusual ex- 
tent or intensity, or when occurring in feeble constitu- 
tions, they may excite fatal constitutional irritation, with 
typhoid fever. 

There are other distinctly mai'ked cutaneous affec- 
tions, which are quite chronic, and merely to be regard- 
ed as perversions of nutrition ; but in regard to all 
the cases now enumerated, it may be affirmed, that they 
begin by inflammation, sometimes of such intensity, as 



INFLAMMATIONS OF THE INTEGUMENTS. 383 



to be naturally associated witli Fever j and tliat in tlieir 
earliest stage, tlieir progress may often be favourably 
influenced by the antiphlogistic regimen, in all its parts, 
and more or less of tlie antiphlogistic treatment. 

In the strictly Ery thematic Inflammation of the skin, 
and in the Diffuse Inflammation of Dr Duncan, asso- 
ciated or allied with it, early general bloodletting is cer- 
tainly in many cases a very powerful remedy, nearly 
assisting or manifestly mitigating the inflammation. 
But there are many cases of these affections, chiefly 
those which result from specific poisons, in which the 
febrile symptoms from the first are typhoid, and the 
general treatment ought to be such as will be after- 
wards stated as proper in typhoid fever. As to the use 
of local bloodletting, there has been much difference of 
opinion. The free detraction of blood by punctures has 
often been followed by speedy reduction of the inflamma- 
tion ; but in some cases it has seemed unavailing, and in 
most cases there is no such danger from the intensity of 
the local inflammation, as to demand a severe remedy. 
The incisions are often useful in a more advanced stage 
of great pain and tension, when suppuration is approach- 
ing, or has begun, — ^but they are by no means to be re- 
lied on as preventing suppuration from proceeding ; and 
much loss of blood in that stage may be immediately 
dangerous, if the symptoms are typhoid ; and may greatly 
retard the convalescence in all cases. 

Several of the strictly cutaneous diseases, particularly 
such as are known to have a long and indefinite course, 
the Lepra, the Eczema, the Impetigo, and the Syphili- 
tic affections, when attended by more than usual of in- 
flammation or fever, are likewise much benefited by 

I general bloodletting ; and most of them, by repeated 

i • 

i 3 



384 OUTLINES OF PATHOLOGY AND PRACTICE. 



purging, particularly, as is generally thought, by some 
of the saline purgatives, combined with sulphur, small 
doses of antimony, or other diaphoretics. 

In the case of those strictly cutaneous diseases, of 
this class, which are known to have a regular and pretty 
uniform course, such as the Erythema, or the Herpes, 
these means, with the mildest cooling, or slightly as- 
tringent applications externally, are the only practice 
required ; the main use of external applications being 
apparently only exclusion of the air. The other ex- 
pedients generally found useful in strictly cutaneous 
inflammations, when becoming more chronic, or re- 
peatedly recurring, and following no definite course, are 
the following :— 

1. Warm bathing, or frequent fomentation with hot 
water, especially when there are hard scales or scabs, 
with a dry rough state of the skin. 

2. Various Diaphoretics, — Antimonials chiefly in 
those cases where there is some fever and firmness of 
pulse, more generally the vegetable diaphoretics, such 
as Sarsaparilla. 

3. Various medicines, adapted to correcting dis- 
order at stomach, especially Antacids and mild laxatives 
at first ; and after a time, when the appetite and di- 
gestion are deficient, and the febrile state or inflamma- 
tion have abated, bitter infusions, with mineral acids, or 
small doses of the preparations of steel. 

4. Diff*erent medicines, which may be called Altera- 
tives or Specifics ; because the good effect which they 
seem to exert on the diseased actions on the skin, is 
not explained by any sensible effect they produce. Of 
these the most unequivocally effectual is Sulphur in 
Scabies : the next in efficacy is Mercury in Syphilitic 

5 



INFLAMMATIONS OF THE INTEGUMENTS, kc. 385 



eruptions ; of which, however, it is to be observed, that 
its effect seems remarkably various in different consti- 
tutions, and that when there is evidence of scrofulous 
affection, its efficacy is most doubtful, and the chance 
of its subsequently injuring the patient, especially if he 
is not well guarded against cold, is the greatest. Small 
and frequent doses of mercurial preparations seem also 
useful in several of these cutaneous diseases, especially 
the Impetigo ; but their efficacy is not so decided as in 
the Syphilitic cases. The most useful of the other 
medicines, which may be called Alteratives, in these 
diseases, are the Sarsaparilla, — the Dulcamara, — the 
preparations of Iodine and of Arsenic,- — the last espe- 
cially, perhaps, in those attended with much itching, — 
the Psoriasis and Prurigo. 

5. Different external applications, of which it may be 
said, in general, that, in the earliest stages, and in ge- 
neral, when the local symptoms are most inflammatory, 
the unctuous applications, merely excluding air, mild 
Liniments, oiled silk, or the soothing narcotic applica- 
tions, made with Opium, Belladonna, or Dulcamara, 
— ^^are the most advisable ; — when there is less heat 
or pain, but more complaint of itching, some of the 
more stimulating saline or metallic preparations, espe- 
cially the Chlorides, the mercurial preparations, or 
ointments containing Pitch, Sulphur, or Zinc, have a 
better effect ; and when there is chronic ulceration, ap- 
plications containing more distinctly astringent and sti- 
mulating substances, — preparations of Zinc — of Mer- 
cury — of Nitrate of Silver or Sulphate of Copper, — 
are found the most useful. As a general rule, in 
the chronic inflammations confined to the skin, although 
going to suppuration, poultices (unless occasionally and 

B b 

I 



386 OUTLINES OF PATHOLOGY AND PRACTICE. 



for a short time) are not advisable ; their ultimate ef- 
fects being generally to extend and prolong the inflam- 
mation. 

There is another state of the system, known by the 
appearances which it produces on the skin, which may 
be noticed here, especially as it is an occasional attend- 
ant of all kinds of inflammatory disease, — viz., the 
Heemorrhagic Diathesis, known by the appearance of 
spots of Purpura; i. e, circumscribed, nearly circular, 
purple spots, changing colour gradually ; in some cases 
approaching to black, on different parts of the skin. 
This kind of eruption is often attended with large or 
irregular spontaneous Ecchymoses or effusions of blood 
beneath the cuticle, or with such effusions produced by 
slight injuries, — also with bleeding at the gums, occa- 
sionally with bloody vomiting and diarrhoea, and, as 
is known by dissection, with effusions of blood on va- 
rious internal viscera. In cases of this kind, blood 
drawn from the veins is usually found to coagulate very 
imperfectly, and uncontrollable haemorrhage may follow 
from a slight wound. 

This state shews itself in some cases without any in- 
flammatory or febrile symptoms ; but in many cases it 
appears, on careful examination, to be complicated with 
the symptoms of inflammation of some part, external 
or internal ; and we have even sometimes reason to sus- 
pect, that the condition of the blood, thus denoted, is 
formed only during the continuance of the inflamma- 
tion. A similar complication occurs occasionally in all 
the strictly febrile and exanthematous diseases, and may 
be easily distinguished, on careful examination, from the 
peculiar eruption of any of them. The causes are quite 



INFLAMMATIONS OF THE INTEGUMENTS, &C, 387 



unknown ; and in particular, notwithstanding its close 
resemblance to the symptoms of Scurvy, it is certain 
that it often occurs in persons previously healthy and 
well fed. 

The occurrence of these symptoms in combination 
with those of any inflammatory disease, necessarily in- 
creases the danger of it, or adds a risk of death occur- 
ring in a manner different from the usual course of the 
disease ; e, g, hj apoplexy, or effusion of blood on the 
mucous membrane of the intestines, or even into the 
thorax ; but it has not appeared by experience, that 
this danger is nearly so great as that which attends the 
complication of the ha3morrhagic diathesis with the 
strictly febrile diseases, particularly the Smallpox. 
And experience has farther shewn, that when the 
symptoms of internal inflammation are well marked, 
they may be met by the usual Evacuations, Blood- 
letting and Purging (practised, of course, with the cau- 
tion which the state of the circulation in other respects 
often demands in such cases), although the heemor- 
rhagic diathesis be present ; and the peculiar condition 
of the blood has often been observed to improve at the 
same time that the other symptoms were relieved by 
these evacuations. 

Various medicines have been employed, in the hope 
of directly diminishing or arresting the morbid condi- 
tion of the blood, or the effusions from it in those cases, 
— ^particularly the metallic astringents,— the prepara- 
tions of Lead, Zinc, and Copper, — the earthy and ve- 
getable astringents; e. g. decoction of oak-bark and 
alum ; the mineral acids ; different preparations of 
Chlorine, and various neutral salts ; perhaps the Sul- 
phuric Acid and Sulphate of Soda have been as well 



388 OUTLINES OF PATHOLOGY AND PRACTICE. 

recommended as any others : — many cases are seen 
gradually to improve under such treatment ; and the 
use of such medicines ought certainly not to he omitted ; 
hut from what we witness in other cases, and especially 
in the strictly fehrile diseases, where this complication 
exists, we cannot place much reliance on the efficacy of 
any of those means. 



( 389 ) 



PART II. 
DIVISION II. 

OF FEVEES PROPERLY SO CALLED. 

CHAPTER I. 

OF IDIOPATHIC FEVER. 

The combination and succession of symptoms, which 
we regard as characteristic of Fever, or febrile action, 
have been ah-eady described ; and it has also been stat- 
ed, that these symptoms, even as occurring in connexion 
with, and apparently in consequence of, inflammation, are 
liable to considerable variety, and particularly to two 
varieties, already designated as inflammatory and ty- 
phoid; of which the latter has this important peculiarity, 
that it may very generally be ascribed to the influence 
of some other cause affecting the constitution, besides 
the inflammation itself. We have now to treat of Fever 
(almost always more or less of this last character), as it 
frequently occurs, either without marks of local inflam- 
mation, or with so slight or so variable marks of that 
kind, that we judge it proper to consider it as quite in- 
dependent of inflammation. 

It is true, that there are eminent pathologists who 



390 OUTLINES OF PATHOLOGY AND PRACTICE. 



doubt of the existence of such Idiopathic Fever ; believ- 
ing all febrile action to be dependent on local irritation 
and inflammation ; but we set aside that doctrine in the 
mean time, simply on the ground, that physicians have 
generally described fevers, of the kind now in question, 
as distinguishable by their symptoms and history, inde- 
pendently of all theory, from any of the certain ai;id 
acknowledged effects of inflammation ; and this being 
• so, it is right to treat of the diseased states thus distin- 
guished, in the first instance, separately ; and afterwards 
to consider the Theory which would resolve the one into 
the other. And although the term Idiopathic Fever may 
appear too theoretical to be used in the first instance, 
yet it is hardly possible to substitute another ; and if it 
be understood that it is at first used to designate pecu- 
liarities of symptoms, independently of all theory, it can 
hardly tend to mislead. 

We set aside also, without hesitation, the objection 
that has been urged against the doctrine of Idiopathic 
Fever, that the term expresses only an abstraction, and 
therefore a nonentity ; because what we mean to express 
by the term is not an abstract existence, as disting-uished 
from individual but a general change, or succession 
of changes, common to all the organs, and to almost all 
the textures of the body, as distinguished from all jt>ar- 
^iaZ changes, and their effects. 

There is a great and important distinction, both as to 
causes and symptoms, between the Intermitting and 
Remitting and the Continued Fevers ; but there are so 
many points of similarity in their whole Pathology, and 
in some cases they graduate so imperceptibly into one 
another, that we shall save repetition by treating them 
together. 



OF IDIOPATHIC FEVER. 



391 



Sect. 1,—Of the Diagnostic Symptoms and Varieties 
of Idiopathic Fever, 

The peculiarities by which Idiopathic Fevers, accord- 
ing to this acceptation of the term, seem to be best dis- 
tinguished, are the following. 

I. There is the negative fact, that in many of the 
cases to which this name is given, the general febrile 
symptoms, — the chilliness and lassitude, the subsequent 
reaction, and often long-continued acceleration of pulse 
and heat of skin, the thirst, anorexia, various uneasy 
sensations, and derangement of all the functions of the 
-body (whether functions of the vascular or nervous sys- 
tem), — -are unattended during great part or the whole of 
their progress by any such local symptoms, — such fixed 
and permanent local uneasy feeling, — or such peculiar 
change of the sensible qualities — derangement of the 
functions of any one part of the body, as justifies the 
belief that any individual organ is inflamed. And if 
these observations be thought ambiguous, on account 
of the occasional occurrence of cases of latent inflam- 
mation, formerly mentioned, the absence of local inflam- 
mation, in many such cases, is farther attested by the 
fact, to be afterwards stated, that they sometimes ter- 
minate fatally, without any satisfactory evidence ap- 
pearing, on dissection, of inflammation of any part of the 
body ; and very generally with so slight appearances of 
that kind, as are inadequate to the explanation of the 
fatal event. 

II. Besides this negative observation, which applies 

5 



392 OUTLINES OF PATHOLOGY AND PRACTICE. 



only to a part of the cases tlius named, tliere is the po- 
sitive observation, applicable probably to all cases of 
idiopathic fever, although much more obvious in regard 
to some than others, that the typhoid symptoms, for- 
merly shortly described (and which may always be held 
to imply the action on the system of some cause distinct 
from mere local inflammation), are distinctly to be per- 
ceived. These typhoid symptoms shew themselves in 
one or other, but generally in several, of the following 
ways. 

1. In the state of the Circulation, the pulse having 
very generally, from the commencement, or early in the 
disease, less strength or resistance to compression than 
in the fever which usually accompanies simple and de- 
cided inflammation, at the same period after the attack. 

2. In the state of the Secretions, which are more de- 
ranged, and generally more diminished, than in inflam- 
matory fever ; as is sufficiently obvious in the fur on the 
tongue, and tKe secretions of the mouth, becoming viscid, 
dry, and dark-coloured ; in the more complete failure 
of appetite; and generally, after a short time, in the 
greater dryness of the surface of the body, attended in 
most cases by a more pungent, though less enduring, 
heat of the surface. 

3. In the state of the Nervous System, the greater 
tendency to stupor or confusion of thought, generally to 
be detected even in the commencement, and very obvious 
in most cases throughout most of the disease, often 
shewing itself unequivocally in the later stages by the 
involuntary voiding of the excretions which are naturally 
under the restraint of the will ; the greater weakness, 
vertigo, and faintness on attempting exertion, in the 
early part of the disease, attended generally with much 



OF IDIOPATHIC FEVER. 



393 



tenderness of surface and general soreness ; the frequent 
tremors and subsultus tendinum, even when no exertion 
is made; the greater derangement of the external senses, 
particularly of that of Hearing ; the greater tendency to 
delirium, as the disease advances, and the usually pecu- 
liar character of that delirium, which extends to all the 
trains of thought in the mind, is unattended with pro- 
pensity to violence, and is more or less blended with, or 
graduates into, stupor, and hence is generally designated 
by the epithets low, muttering. 

4. In the state of the Blood, which is probably always 
so far altered in its vital properties, in idiopathic fever, 
as to coagulate less firmly than usual, and in some cases 
loses the power of coagulation altogether ; in connexion 
with which state we frequently observe more or less of 
the symptoms formerly called those of putrescency in 
fever, petechise or vibices, passive haemorrhages, and 
gangrene from slight irritation. 

5. These symptoms, and especially the indications of 
nervous affection, and of putrescent tendency, are very 
generally sufficient to distinguish idiopathic from any 
form of inflammatory fever ; but in many cases there is 
a farther positive distinction in the appearance of pecu- 
liar or specific inflammations of the skin^ subsequent to 
the attack of the fever, which take different forms, — 
essentially characterizing the fevers that are designated 
as eruptive or exanthematous, — often appearing also in 
the simple continued fever, — but never forming any 
part of the constitutional symptoms that result from 
local inflammation exclusively. 

III. A most important part of the history of what we 
call idiopathic fever, distinguishing it from the acknow- 



394 OUTLINES OF PATHOLOGY AND PRACTICE. 



ledged effects of inflammation, is its much greater ten- 
dency to a spontaneous favourable termination. This is 
shewn in different ways. In many cases the febrile 
symptoms return at regular intervals of 24, 48, or 72 
hours ; and subside completely after a cold and hot fit 
of some hours' duration, by a spontaneous sweating, — 
constituting the Intermitting form of fever. In others 
there are equally distinct, but less perfect and less re- 
gular remissions of the symptoms, and the term applied 
is Remittent fever. And in the remaining or -Continued 
form of Idiopathic Fever, although we can observe only 
slight and partial abatement of the symptoms at differ- 
ent hours of the day, we very often observe complete 
recovery from the most urgent and distressing symp- 
toms, taking place spontaneously at various periods of 
the disease, — sometimes, in the fever of this country, as 
early as the 7th or even the 5th day ; sometimes not 
until the 30th, or even 40th day, most generally between 
the 10th and 20th ; sometimes very rapidly, and with 
evacuations (whether at regular or irregular times) evi- 
dently resembling the sweating stage of intermittents ; 
sometimes gradually, and without any such critical eva- 
cuations ; but under very various treatment, — often 
without the use of remedies, — and always with less as- 
sistance from remedies, and with much less risk of sub- 
sequent organic disease, thaR where recovery takes place 
from an equally disordered state of the system, conse- 
quent on decided internal inflammation. 

IV. There is this farther leading peculiarity in the 
cases of febrile disease, to which we give the name of 
Idiopathic Fevers, that they are often absent for a 
length of time, even from large communities, and again 



OF IDIOPATHIC FEVER. 



395 



at other times, or in other districts, are extremely pre- 
valent ; and therefore evidently do not proceed merely 
from causes which are of general operation, as the ex- 
citing causes of inflammation are, but must necessarily 
result from causes of more local and temporary agency ; 
and accordingly, we have good evidence, that all these 
idiopathic fevers either originate from a Malaria, or pro- 
pagate themselves in part at least, and in certain cir- 
cumstances, by Contagion. 

By attention to these particulars in the history of 
many febrile disorders, even independently of attention 
to the results of practice, we are authorized to conclude, 
that they may be distinguished from the effects of simple 
inflammation, and belong to the class which we call, for 
the present. Idiopathic Fevers ; and that the onus pro^ 
handi rests with those who would attempt to assimilate 
them to, or resolve them into, the acknowledged effects 
of inflammation. 

But these Idiopathic Fevers are liable to very consi- 
derable varieties ; and, setting aside for the present the 
Eruptive Fevers, we may enumerate two distinct heads 
of these varieties ; in the first of which the distinctions 
lie in the essential symptoms of the febrile action itself ; 
in the second, in the indications of local and general in- 
flammatory disease, which attend it frequently, although 
not uniformly, and therefore not necessarily. 

I. 1. There is a form of fever, of rare occurrence, but 
of great pathological importance, which has been lately 
described under the title of Congestive; and although 
that term expresses what is probably a concomitant, ra- 
ther than the cause of the peculiarity of the symptoms, 
yet it is perhaps better to endeavour to fix its meaning, 
than to substitute another. 



396 OUTLINES OF PATHOLOGY AND PRACTICE. 



In this variety of fever, tlie symptoms of the earliest, 
or cold stage, assume their highest degree of intensity ; 
and feebleness of pulse, coldness of surface, muscular 
debility, and depression of all the functions of the ner- 
vous system, approaching, and sometimes amounting, to 
complete coma, are the leading symptoms. Spasms at- 
tend some cases of this kind, and vomiting attends others. 
Such cases occur now and then in epidemics of common 
continued fever, but are more frequent in the most ma- 
lignant epidemic diseases, PlagTie, Yellow Fever, Cy- 
nanche maligna ; and many cases of Epidemic Cholera 
are closely analogous to them. In all these cases, if 
this first and very dangerous effect of the remote cause 
of the disease is recovered from, it is usually succeeded 
by a distinct^ but generally feeble, febrile reaction. 

2. What is called the Inflammatory form of Idiopathic 
Fever, is the most widely different from the congestive 
form. In this case, the depression in the first or cold 
stage is the least, and the febrile reaction is the strongest, 
the pulse full, firm, and frequent, the skin hot and re- 
tentive of its increased temperature ; the thirst intense, 
the urine 'generally high coloured, the face often flushed, 
and the febrile pains of head and other parts intense ; 
the senses often preternaturally acute, and the delirium, 
if present, attended with increased rapidity of thought, 
and sometimes with violence. 

In all cases of idiopathic fever, these symptoms, sooner 
or later, imdergo a change, and pass into the typhoid 
form more or less completely ; but the cases in which 
the symptoms now mentioned are the best marked, and 
last longest, and where the subsequent typhoid stage is \ 
the least obvious, have the general name of Inflamma- 
torv Fever. 



OF IDIOPATHIC tEVER. 



397 



3. On the other hand, the name of Typhoid Fever is 
given to those cases in which, after the febrile reaotion 
has been established, the typhoid symptoms already enu- 
merated,* — in the state of the circulation, of the secre- 
tions, of the nervous system, and of the blood, are ear- 
liest observed, and are most urgent. 

The term Malignant, as applied to fevers, may be said 
to include the rare congestive, and the frequent typhoid 
fever ; as applied to epidemics, to denote those in which 
cases of these two descriptions are the most frequent. 

Under the general name of Typhoid Fevers, we may 
describe three subordinate varieties, which it is in some 
cases easy and important to distinguish ; but which in 
most instances are blended together, or graduate into 
one another. 

a. When the most obvious and urgent of the t)q)hoid 
symptoms are those of mere debility of the vital actions, 
—soft compressible pulse, dry foul tongue and lips, de- 
ficient or easily depressed heat of the surface, and ex- 
treme muscular debility, shewn in the voice and attitude 
as well as in the muscular movements, — the name of 
" Fievre Adynamique " is given by recent French 
authors, and the term Low Fever is the most appro- 
priate in our language. 

h. When the most obvious and urgent of the typhoid 
symptoms are those indicating derangement of the func- 
tions of the Nervous System, — pervigilium, restlessness, 
tremors or spasms, deafness, contracted pupil, and other 
affections of the external senses, delirium, especially of 
the more active kind, and this afterwards subsiding into 
stupor— the case has been styled " Fievre Ataxique" by 

* See p. 392. 



398 OUTLINES OF PATHOLOGY AND PRACTICE. 



the Frencli, and is generally called Nervous or Brain 
Fever in this country. This form of fever is most re- 
markably seen in persons in whom the nervous system 
has been previously and habitually excited, either by 
voluntary muscular or mental exertion, or strong and 
lasting emotion, — or by the inordinate use of stimuli, 
such as alcohol. 

c. When the most obvious of the typhoid symptoms 
are those denoting a dissolved state of the blood, pe- 
techiee, passive haemorrhages, gangrene from slight irri- 
tations, &c. the case has still among many the name of 
Putrid Fever. 

All these varieties may be observed in cases where 
neither the symptoms before death, nor the appearances 
after death, give any clear indication of inflammation in 
any individual organ ; and may be said therefore to be 
different forms of Simple Fever, 

II. The more complex and most generally dangerous 
forms of fever, are those where the symptoms, especially 
of the typhoid fever, are combined, either from the first 
or during their progress, with such symptoms as indi- 
cate, with more or less certainty, local Inflammatory 
Action in some part of the body ; and these are most 
simply divided into Fevers with affection of the head, 
chest, or abdomen. 

It may be stated generally, that inflammations of cer- 
tain organs in the body are very apt to combine them- 
selves with general fever ; but that the course of these 
inflammations is evidently modified ; the fixed pains at- 
tending them are generally less acute ; their other symp- 
toms often become protracted, and remain nearly sta- 
tionary for a longer time than in other cases ; and they ' 



OF IDIOPATHIC FEVEK. 



399 



tend, as will afterwards appear, to terminations whicli 
are in some respects peculiar. The modifying effect of 
fever on local inflammation, is seen where fever attacks 
a person in whom any cutaneous inflammation and effu- 
sion are going on ; the appearance of which is usually 
much altered, and the discharge often suppressed during 
the febrile state. 

1. It is obvious that many of the symptoms of affec- 
tion of the brain which occur in fever, are the same as 
attend cases of unequivocal inflammation of the Brain, 
e. g. the headache, often violent ; the impatience of light 
and sound ; frequent nausea and vomiting ; the indica- 
tions of determination of blood to the head ; the delirium, 
of various character, spasms of various muscles ; and 
ultimately Coma. Such symptoms are perhaps chiefly 
seen in the fevers of the hottest weather of this climate, 
and in those of warmer climates. It is also certain, as 
will be stated afterwards, that unequivocal effects of in- 
flammation have been occasionally found on dissection, 
after fatal fevers ; that more or less effusion of serum 
within the cranium, which was described as the first 
effect of inflammation there, is common in such cases ; 
and that the remedies for inflammation, early and pru- 
dently applied, have often appeared to relieve very con- 
siderably the symptoms of affection of the Nervous Sys- 
tem occurring in fever ; and therefore, although we shall 
afterwards see reason to believe that the affection of the 
brain in fever is by no means simply inflammatory, but 
partly dependent on another cause, yet we may consider 
it as ascertained, that a degree of inflammation within 
the cranium (generally best designated by the title of 
Subacute), does often accompany idiopathic fever ; and 
is to be apprehended when the symptoms above men- 



400 OUTLINES OF PATHOLOGY AND PRACTICE, 



tioned are urgent, and when there appears to be danger 
of death strictly in the way of coma, rather than by 
reason of the circulation being enfeebled. 

2. There are many cases of fever, especially in winter 
and spring, in which an inflammatory affection of the 
organs of Respiration^ marked by cough, hurried or la- 
borious, and sometimes stridulous breathing, and more 
or less of pain of chest, either accompanies the disease 
from the commencement, or supervenes during its pro- 
gress ; and in a number of these, it is obvious that death 
takes place, or is strongly threatened, by Asphyxia, from 
the embarrassed state of the respiration, rather than by 
Asthenia, from the weakened state of the circulation. 

This affection of the chest, besides being attended with 
more or less of the typhoid symptoms, formerly men- 
tioned, which make no part of the symptoms in ordinary 
cases of idiopathic bronchitis or pneumonia, has a course 
considerably different from those diseases. It is often 
of long duration, is apparently less under the influence 
of active remedies ; and although it may be moderated 
or restrained, is seldom observed to subside completely, 
until the period of spontaneous abatement of the fever, 
which, . in such cases, is often long protracted. The 
cough and dyspnoea are generally much more urgent 
symptoms in this combination of pectoral affection with 
fever, than the pain of chest ; and the symptoms ob- 
served by auscultation and percussion, and the appear- 
ances on dissection, clearly indicate that the mucous 
membrane of the bronchise, and parts of the substance 
of the lungs, are very liable to inflammation, of a some- 
what peculiar character, in the course of fever, but that 
inflammation of the serous membranes within the chest 
is very rare. 

8 



OF IDIOPATHIC FEVEH. 



401 



3. The affections of tlie abdominal viscera, frequently- 
attending idiopathic fever, are somewhat various. An 
attack of jaundice, at least of yellowness of the skin, in 
the course of the disease, is frequent and very dangerous 
in the fevers of hot climates, and occurs occasionally in 
this. It is often attended with pain and tenderness in 
the situation of the liver, and such affection of the breath- 
ing, such nausea and vomiting, as usually attend inflam- 
mation of the liver ; but in some cases, it is unattended 
with such symptoms. In some cases, it is unattended 
with the usual indications of jaundice in the stools and 
urine ; and in general, it has appeared, on dissection, 
unconnected with any visible obstruction of the gall-ducts. 

In other cases of fever, without jaundice, there is so 
much pain and tenderness in the situation of the sto- 
mach, and nausea and vomiting, increased by all ingesta, 
as to justify the belief of inflammation (generally sub- 
acute) in the stomach itself. These affections, both of 
the liver and stomach, in fever, if not early checked, are 
frequently followed by sudden increase of the symptoms 
of affection of the brain, and by rapidly advancing coma. 

But the most common abdominal affection in fever, 
in this climate, is that in which the intestines are chiefly 
concerned, which comes on at different times, but chiefly, 
and with most danger, in the later stages ; and this is 
marked sometimes by severe pain and tenderness, but 
in general chiefly by diarrhoea, seldom violent, but often 
obstinate ; it is attended with occasional griping (often 
aggravated by ingesta), sometimes with scanty mucous 
and bloody stools and tenesmus, as in dysentery, but 
more frequently without such symptoms. It is often 
accompanied with gradually increasing tympanitic dis- 
I tention, and often occasions long protraction of the 

r • c c 



402 OUTLINES OF PATHOLOGY AND PRACTICE. 



typhoid febrile symptoms, in tlie course of whicli great 
emaciation, extreme debility, and often a peculiar dry- 
ness of the skin, are observed ; and in a few cases it is 
followed, either by sudden exhausting hsemorrhage, or 
by a sudden attack of acute pain and tenderness of ab- 
domen, with vomiting and rapid sinking. 

It is well ascertained that such abdominal symptoms 
in fever depend very generally on inflammation of the 
mucous membrane, and especially of the mucous glands 
of the intestines ; that this inflammation tends rapidly 
to ulceration ; and that the attacks of sudden hsemor- 
rhage or of acute pain and tenderness in the advanced 
stages of such cases, usually depend on erosion of blood- 
vessels, or perforation of the whole coats, and escape of 
the contents of the intestines into the cavity of the ab- 
domen, in the course of that ulceration ; but that in- 
flammation commencing in, or confined to, the perito- 
neum, is equally rare in fever, as that of the serous 
membranes within the chest. 

Besides these inflammatory appearances in internal 
parts, often found after fatal fevers, there are many 
cases of external inflammation going on to ulceration, 
and often to gangrene, which attend the later stages of 
fevers. These may often be ascribed to accidental irri- 
tation, such as pressure, or the dribbling of urine. They 
sometimes occur, especially in the extremities, without 
any assignable cause ; but from the time and mode of 
their occurrence, are always regarded as efl'ects or ac- 
companiments of the fever. 

The difl'erent local afl'ections now described frequently 
succeed each other, or are combined, in the course of 
fever, in the same patient ; and observation of the symp- 



OF IDIOPATHIC FEVER. 



403 



toms of the later stage of most fatal fevers, at least in 
this climate, sufficiently indicates that the danger most 
generally results from a combination of one or more of 
these local affections with the typhoid form of the fever, 
and especially with the enfeebled state of the circula- 
tion. 

Whenever the symptoms of any local inflammation 
have combined themselves with those of general fever, 
it is to be apprehended that the fever will be much pro- 
tracted ; and in fact, it is frequently by the protraction 
of the case, rather than by the intensity of any local 
symptoms, that we are led to suspect the local diseases, 
of which the evidence may afterwards appear on dis- 
section. There are also great varieties, not only in dif- 
ferent individual cases, but in different epidemics, as to 
the average duration of the disease, and as to the in- 
tensity of the inflammatory, or the typhoid symptoms, 
the frequency of eruptions, or the indications of a dis- 
eased state of the blood, — which cannot be ascribed to 
the influence of any external causes, and must be held 
to denote varieties in the nature and virulence of the 
remote cause of the disease. 

But although we consider it of real importance to 
mark these distinctions, both in the essential symptoms 
of Fever itself, and also in: the concomitant local aff'ec- 
tions which distinguish individual cases, and sometimes 
epidemics, from each other, yet it appears equally certain, 
— from consideration of the nature of these distinctions, 
of the manner in which the varieties, thus marked, 
graduate into one another, or are blended together in 
the same cases, and by the many varieties which pre- 
sent themselves in the same epidemic, and in immediate 
connexion with each other, — that all the continued fe- 



404: OUTLINES OF PATHOLOGY AND PRACTICE. 



ver^ of this climate must be regarded as fmidameiitally 
tlie same disease. 

The Intermitting and Remitting Fevers have ob- 
viously, from what was already said of their charac- 
teristic symptoms, as well as from their remote causes, 
peculiar characters, and may be regarded as varie- 
ties of a disease different from Continued Fever, al- 
though so closely allied to it, as to be properly in- 
cluded in the same genus. In the warmer climates, 
and especially in the lower grounds in these climates, 
the external cause of this disease acts with the greatest 
virulence ; and in these, it is doubtful whether the con- 
tinued fever of this climate really exists. But it is cer- 
tain that the remittent fevers there, in their highest de- 
gree of intensity, have nearly the continued form ; and 
they are then attended with great danger, and shew the 
following peculiarities : — 1. That their whole progress 
is much more rapid than that of fevers in this cli- 
mate ; 2. That the symptoms denoting inflammation or 
an approach to inflammation of the brain are often 
more urgent, in the first instance, than here ; and 3. 
That the symptoms of inflammation, or a state nearly 
resembling inflammation, of the liver and stomach, 
with or without the occurrence of jaundice, are more 
urgent, and much oftener appear concerned in the fatal 
event. 

In difl*erent cases, and in difl'erent epidemics, of the 
fevers of hot climates, there is a variety as to these 
concomitant local symptoms ; but it appears clearly that 
there is also a variety, in diff'erent seasons and situations 
in these climates, as to the intensity or malignity of the 
proper febrile symptoms ; the depression of the vital 



or IDIOPATHIC FEVER. 



405 



power in the circulating system, and the symptoms of 
dissolved state of the blood, shewing themselves much 
earlier, more extensively, and more intensely in some 
seasons than in others. When this is the case, the re- 
missions are the least obvious, and it is on such occasions 
that a doubt still exists, whether the remittent fever 
does not acquire that most important property of the 
continued, the power of spreading by contagion. 

In the colder climates, where fever from Malaria takes 
the intermitting form, they are distinguished from each 
other by the length of the intervals intervening between 
the attacks of rigors, which in the quotidians is about 
24 hours, in the tertians 48, and in the quartans 72, 
often kept very exactly. Of these the quartans are 
generally seen only in cases of some standing, often 
complicated with organic disease, and are usually the 
most intractable. The intensity of the cold fit bears 
no regular proportion to the violence of the rest of the 
paroxysm, being greatest in the quartans, where the fe- 
brile reaction is generally the least. Under the treat- 
ment usually adopted, the disease is seldom in itself 
dangerous, although its complications and sequelae, 
— chiefly chronic affections of the abdominal viscera, — 
often are. It is often found, however, exceedingly in- 
tractable, or apt to recur, as long as a patient lives in a 
country where the malaria exists. 

It may be stated, in concluding this account of the 
symptoms and varieties of Fever, that after the febrile 
action has subsided, and the patient begun to become 
convalescent, he is left in a state of weakness and perhaps 
irritability, in which he is peculiarly liable to inflamma- 
tory attacks ; the symptoms of which are often obscure, 
or nearly latent, and very easily confounded with those 



406 OUTLINES OF PATHOLOGY AND PRACTICE. 

of the preceding fever, insomuch that it is often diffi- 
cult to judge, whether death is to be ascribed to fever, 
or to some of these its immediate consequences. 

Scrofulous affections are likewise very apt to be ex- 
cited by their usual causes, after the cessation of idio- 
pathic fever ; and various other organic diseases often 
take their origin at that time. In the case of intermit- 
ting fevers, and especially of those which are of long 
duration, and in which the cold stage is long and violent, 
enlargements of the liver and spleen are peculiarly apt 
to take place towards the close of the disease, or after 
its decline. 

Sect. II. — Of the Appearances on Dissection after 
Idiopathic Fevers. 

The first fact to be borne in mind in this part of the 
subject is the occasional entire absence, after fatal fever, 
of any appearances, which can be strictly called morbid ; 
i, e. of any which are not frequently observed, in eases 
either of sudden and violent death, or of death from 
causes allowed to be unconnected, either with general 
febrile action, or with any symptoms of disease of the 
parts, where they are found. It may be allowed that 
this is a rare case ; but it is not on that account the less 
pathologically important, and it is admitted by the most 
accurate morbid anatomists as an unequivocal result of 
their inquiries. 

Next, it is to be observed, that the morbid appear- 
ances, found after fatal fevers, are often observed to be 
remarkably various, even in cases, the leading symp- 
toms of which are nearly the same ; and that they are 



OF IDIOPATHIC FEVER. 



407 



far from bearing any fixed proportion to the intensity of 
tlie symptoms of affection of the parts where they are 
found. 

This may be ascribed in a great measure to the en- 
feebled state of the circulation at the time when these 
local affections take place, rendering them, as has been 
already stated, frequently latent. 

In regard to the nature of the morbid appearances 
which are found after death by fever, it is to be observed, 
that they are almost uniformly indications of inflamma- 
tion ; but this inflammation is distinguished by two pe- 
culiarities, jirst^ that it is seated very generally in cer- 
tain textures only ; and, secondly^ that its effects are ap- 
parently more limited than in other cases, and in parti- 
cular the effusions of coagulable lymph and of pus are 
found to a very small extent, in comparison with what 
is seen in idiopathic inflammation of the same parts. 
Indeed there are so many fatal cases of fever, attended 
with evident local affections, and shewing on dissection 
marks of local inflammation, in which no effusion of 
lymph or pus appears on dissection, that it may be 
suspected, in the comparatively few cases where con- 
siderable effusions of these kinds have been described, 
that they had resulted from simple inflammation im- 
mediately succeeding (as often happens) to the fever, 
rather than that they had taken place during the fever 
itself. 



I. Within the cranium, the morbid appearances found 
after death from fever, are in by far the greater number 
of cases, confined to increase of the natural serous exha- 
lation on the different surfaces, particularly in the ven- 



408 OUTLINES OF PATHOLOGY AND PRACTICE. 

tricles, and beneath the arachnoid coat ; — in which situ- 
ations in the case of fever (although not in strictly in- 
flammatory cases) the increased exhalations are very 
generally found simultaneously. This effusion may be 
held to be morbid, whenever it is of such extent as ob- 
viously to distend the ventricles, to elevate the arach- 
noid coat, or to widen the depressions between the con- 
volutions of the brain.* 

Such morbid effusion is probably the most frequent 
of any morbid appearances after continued fever in 
Scotland ; but it is to be observed, that it is frequently 
found likewise after inflammatory diseases, in which 
abundant cause of death appears on dissection in other 
parts of the body. It is also found after many cases of 
chronic disease of different parts of the body ; and this 
circumstance renders it somewhat difficult to judge, how 
far it can really be regarded, in the cases now in ques- 
tion, as an effect of fever ; but when it is found in a per- 
son who was in perfect health ten or fourteen days be- 
fore his death, and in whom febrile symptoms and affec- 
tions of the head resembling the usual effects of inflam- 
mation there have intervened, we cannot hesitate about 
regarding this, which is an acknowledged result of in- 
flammatory action, as a morbid appearance strictly con- 
nected with the fatal fever. It is important, however, 
to observe, that the whole amount of this effusion within 
the cranium, in cases of fever, very seldom amounts to 
an ounce ; and is very generally much less than, in fatal 
cases of idiopathic inflammation within the cranium, 
whether acute or chronic ; and farther, that it occurs 



* See Andral, Clin. Med. t. i. p. 418. 



OF IDIOPATHIC FEVER. 



409 



more generally in tlie bodies of persons advanced in life 
than of young persons, whatever the character of the 
fever may have been. 

An injected or unusually turgid state of the bloodves- 
sels within the head, especially of the pia mater and 
substance of the brain, is often observed after fatal 
fevers, and is probably often an effect of the same con- 
dition of the vessels, from which the effusion results ; 
but agreeably to what was formerly said, we are not en- 
titled to deduce from that appearance alone, any infer- 
ence as to inflammation, or even morbid congestion of 
blood in the part before death. 

In a few instances, after fatal fever, a little extrava- 
sation of blood has been found within the cranium ; and 
in a greater number, where paralytic strokes have taken 
place in the course of fever, we are pretty certain that 
such extravasation has occurred. In a few cases also, 
effusions of lymph on the cerebral membranes, and even 
deposits of purulent matter, either circumscribed or dif- 
fused, have been found ; but in some of these, at least, 
it may be doubted whether these decidedly inflamma- 
tory effusions had taken place during the true febrile 
state. 

The appearances now mentioned may be supposed to 
have connexion with the comatose tendency, and the 
death in the way of coma in Fever ; but they are some- 
times altogether absent in cases of that kind, and their 
amount cannot by any means be anticipated from ob- 
serving the duration or intensity of that tendency. It 
is certain, that neither unusual hardness, nor unusual 
softness, of the substance of the brain, is uniformly, or 
even very frequently, connected with the symptoms of 



410 OUTLINES OF PATHOLOGY AND PRACTICE. 



fever, raid iliat any indications of disease of the dura 
mater during fever are very rare. 

In the Spinal Cord, appearances similar to those now 
described in the brain, have been occasionally observed, 
but do not appear to be very common, nor can any uni- 
form connexion be traced betvf een the appearances there, 
and spasms or other affections of the voluntary muscles 
in fever. 

II. The morbid appearances found in the air-passages 
and within the chest after fatal Fever, and which are 
often evidently connected with the death by Asphyxia 
in fever, are the following, 

1. There is, in a few cases of fever, an inflammation, 
generally a peculiar aphthous inflammation, of the mu- 
cous membrane of the fauces and larynx, and the thick- 
ening and exudation in the latter part may be to such 
extent as to embarrass the respiration very materially, 
and conduce to the fatal event. But it is very seldom 
that the mechanical impediment to the access of air 
to the lungs, produced by inflammation of this part 
during the progress of the true febrile symptoms, is very 
great. 

2. In a great proportion of fatal cases of fever, more 
or less of the usual indications of inflammation of the 
mucous membrane of the bronchi as, vascularity and 
thickening, and efl'usion of viscid or frothy mucus, are 
found on dissection ; and in some cases these effects of 
Bronchitis are so general, in both sides of the chest, as 
to afford a satisfactory explanation of much dyspnoea, 
and of death by asphyxia. 

3. In a considerable number of cases there is found a 



OF IDIOPATHIC FEVER. 



411 



decidedly morbid amount of serous effusion into the pul- 
monary cellular substance itself, wbicli is discharged on 
cutting and pressing that substance. 

4. In many cases there is found after fatal fever, con- 
densation of part of the substance of the lungs, known 
by its not crepitating under the knife, and often like- 
wise by its sinking in water, and attended with soften- 
ing. But this condensation very generally differs from 
the hepatization formerly described, in having a darker 
and more uniform colour, and not shewing the charac- 
teristic appearance of granular decolorized lymph. 

In regard to these appearances in the substance of the 
lungs, it is to be observed, that they frequently coexist 
with the indications of Bronchitis already mentioned ; 
and that in such cases, if they are found only in the pos- 
terior or depending portions of the lungs, and nearly 
alike in both sides of the chest, although not strictly 
post-mortem appearances, yet they indicate only conges- 
tion of blood, and consequent extravasation taking place 
within the last few hours of life ; when the blood, in con- 
sequence of its defective arterialization, and of the en- 
feebled action of the heart, is making its way so slowly 
through the capillaries of the lungs, that it is liable to 
the influence of gravitation, and stagnates so much in 
the lowest of the vessels of the lungs, as to distend these 
vessels permanently, and to transude from them more 
or less completely into the adjacent cellular substance. 

That these results should follow from the languid 
movement of the blood through the lungs, in this and 
other acute diseases, when the blood is in full quantity, 
its vitality probably impaired, its arterialization im- 
peded, and the powers propelling it much depressed, is 



412 



OUTLINES OF PATHOLOGY AND PRACTICE. 



what may readily be anticipated ; and that this is the 
real explanation of the appearances now described, in 
many cases of fever, seems sufficiently demonstrated by 
their occupying so strictly, in many such, the depend- 
ing portions of the lungs, — by their being often found 
in that situation where no pneumonic symptoms had 
occurred, — and by two observations of Laennec, — 1. 
That he had repeatedly satisfied himself, by ausculta- 
tion, of the commencement of this " Peripneumonie des 
Agonisans," only at the time when the powers of life 
were prostrate ; and, 2. That in one case, where, in 
consequence of sores on the back, the patient was con- 
strained to lie on his face, for some time before death, 
the very same appearances were found in the anterior 
(but still the depending) portions of the lungs. 

When the effusion of serum, or extravasation of en- 
tire blood, into the cells of the lungs, are found in parts 
that do not lie lowest, or are variously dispersed through- 
out the lungs, it may confidently be inferred that they 
are the effects of an inflammatory action; but some- 
what modified by the presence of the typhoid fever, so 
as to give results in some measure diflferent from what 
are seen after other cases of inflammation there. 

5. There are some cases, in which real gangrene of 
the lungs, known by perfect flaccidity and putrid smell, 
and generally denoted before death by the peculiar foetor 
of the breath, is found as a consequence of inflammation 
of the lungs, accompanying Fever ; as in other cases 
where pneumonic inflammation is attended with great 
weakness of the circulation. 

Evidence of inflammation of the pleura or pericardium 
is very rarely seen after idiopathic fever, except in cases 



or IDIOPxiTHIC FEYER. 



413 



where the progress of the symptoms gives reason to be- 
lieve that a simply inflammatory attack had supervened 
on fever already on the decline. 

6. Probably the most characteristic appearance, 
usually to be observed in the Thorax after fever, is the 
morbid Fluidity of the Blood ; sometimes this is com- 
plete, in the cases of most rapid progress ; more gene- 
rally there is partial coagulation and even decoloriza- 
tion, but to a small extent, in comparison of what is ob- 
served after most simply inflammatory, or even febrile 
diseases. 

III. The alterations of the Liver found after fever, 
and which can be regarded as consequent on it, even 
where there has been yellowness of the skin, very sel- 
dom amount to more than partial enlargement and 
softening, and injection of minute vessels. 

In the Yellow Fever, and in some cases at least of 
Jaundice during fever in this climate, it is well ascer- 
tained, by Louis and others, that neither obvious disease 
of the Liver, nor obstruction of the ducts, attends the 
disease, so that the case must be considered as Jaundice 
from non-elimination of Bile, analogous to the Ischuri 
Renalis, and in the former case, indeed, usually asso- 
ciated with great deficiency, or absolute suppression of 
urine. 

In the Spleen, morbid softening is more common ; and 
much but various alteration of the appearance of the bile, 
after fatal fevers, has been remarked by Andral and 
others, and is important to be noticed, as it may pos- 
sibly be concerned in producing the affections of the in- 
testines now to be mentioned. 

The morbid appearances in the mucous membrane of 



4:14: OUTLINES OF PATHOLOGY AND PRACTICE. 



the Stomacli and Bowels often seen after fever, demand 
careful attention. They are seen frequently m cases 
where there has been much affection of these parts during 
life, but bear no fixed proportion to the intensity of the 
symptoms denoting such affection ; and in cases that are 
long protracted, they are often observed to an unexpect- 
ed extent, when the functions of the bowels had appeared 
to be very little deranged. 

It may be said in general, that these appearances differ 
from those commonly seen after idiopathic inflammation 
of the same parts {e. g. in dysentery), in the inflamma- 
tion being here more limited to spots on the membrane, 
and the eff'usion of lymph consequent on it being to a 
much less extent. 

The marks of inflammation of this membrane found 
after death by fever, are generally the following. 

1. Brownish-red patches, generally with a reddish 
coloured mucus lying on them. But this appearance, if 
confined to parts that lie lowest in the position of the 
bod}^ in the last hours of life, and after death, is by no 
means to be trusted as an indication of previous inflam- 
matory action. 2. Softening and thickening of the 
membrane at the parts so discoloured, which, if accu- 
rately and carefully described, are much better signs of 
real disease than any variations of mere colour.* 3. 
Effusions of lymph, in spots dispersed over the surface, 

* In tlie fevers of hot climates, u'hicli are so rapidly fatal, the 
morbid appearances found in the abdomen, and connected with the 
incessant retching, and ultimately with the black vomit, are gene- 
rally confined to the appearances now described, existing often in an 
intense degree in the mucous membrane of the stomach, buj without 
exudation of lymph or ulceration. 



OF IDIOPATHIC FEVER. 



415 



wliich adhere for a time to the mucous membrane it- 
self, and sometimes take much the form of exanthe- 
matous diseases. 4. Ulcers of various size and form, 
generally rather thinly scattered, excepting at the lov/er 
end of the ileum, where they are often set m clusters ; 
very generally preceded by some effusion of lymph, 
and formed sometimes by the ulcerative absorption 
only, in other cases in part by sloughing of the mem- 
brane. 

All these appearances are observed sometimes in spots 
of the mucous membrane itself, but more generally in 
the portions of that membrane already occupied by the 
small mucous glands, named Glands of Peyer and 
Brunner. They are most common in the ileum, espe- 
cially its lower extremity, next in the caecum and colon, 
and next in the stomach, and are rarest m the duode- 
num. They are very often attended with vascularity 
of the corresponding parts of the mesentery, and enlarge- 
ment and injection of the corresponding mesenteric 
glands. 

Such unequivocal disease of the mucous membrane of 
the alimentary canal is found, either alone, or in com- 
bination with the other diseased appearances above men- 
tioned, in a majority of the fatal cases of continued fever, 
which occur in Paris, and in a large proportion of those 
that occur in London ; but in a much smaller proportion 
of fatal cases in Scotland. They are decidedly more 
frequent, at least in this country, after the fevers of 
children and young persons than in advanced life; and 
in fevers that are fatal at an advanced period than in 
those that are rapidly fatal. 

"We have good evidence that the ulcers thus formed 
may be afterwards cicatrized ; but there are also a cer- 



416 OUTLINES OF PATHOLOGY AND PRACTICE. 



tain number of cases, in which dissection shews that 
the ulceration has extended to vessels of such size as to 
give a copious discharge of blood ; and others in which 
it has led to perforation of the whole coats of the in- 
testines, escape of their contents, and consequent rapid 
and fatal inflammation of the peritoneum. These 
effects of the ulceration are almost always made known 
by the sudden attacks of haemorrhage, or of violent pain 
and sinking, formerly mentioned ; and these symptoms 
sometimes commence at so late a period after the febrile 
action has subsided, as to indicate that the fever is by 
no means necessarily coexistent with the formation or 
even the extension of these ulcers. 

It is important to observe, that the external inflam- 
mations which often attend the later stages of fever, 
both those caused by irritation, such as pressure, and 
those which occur spontaneously, e,g. in the parotid 
glands, or in the feet and toes, are found to exhibit cha- 
racters, during life, and after death, which distinguish 
them from the more usual inflammations of the same 
parts ; they often tend to ulceration, and often to gan- 
grene, but seldom to effusion of healthy pus, and hardly 
ever to the formation of granulations, while the general 
febrile action continues. 

When pains are taken to distinguish the truly morbid 
appearances left by fever, from appearances (such as 
staining of the inner membrane of arteries, or of the 
mucous membrane of depending portions of bowels) 
which may be fairly ascribed to changes taking place 
after death, in a body where the coagulation of the 
blood is imperfect ; — and likewise from the efi*ects of 
inflammations often rapidly supervening during the con- 
valescence from fever ; — we shall not be authorized to 



OF IDIOPATHIC FEVEK. 



417 



consider more phenomena than those now described, as 
certainly belonging to the former class. When the 
more chronic sequelae of fever prove fatal, they leave a 
much greater variety of appearances behind them. In 
particular, when the enlargements of the liver and 
spleen, often consequent on Intermittent Fever, end in 
fatal chronic disease, the appearances usually found are 
just the same as are common, when there has been 
long-continued obstruction to the course of the venous 
blood in the thorax, and consequent congestion in these 
viscera j— viz. enlargement, hardening, increase of the 
whitish cellular substance in the parenchyma, or, as is 
now thought, in the fine membranous expansions, conti- 
nuous with the capsule of Glisson, which extend through- 
out the substance of the liver, — and ultimately the 
development of granules or tubercles there. And the cir- 
cumstances preceding the formation of such organic dis- 
ease, in the case of long-continued intermittents (espe- 
cially Quartans, where there have been frequent long 
cold stages, implying congestion of blood in the great 
veins, and at the same time febrile circulation), and, 
again, in cases of mechanical obstruction of the venous 
circulation, — mutually illustrate one another. 



Sect. III. — Of the Remote Causes of Idiopathic 
Fevers. 

Referring, first, in this part of the subject, to what 
has been already said (p. 61, et seq.), of the marks by 
which we can confidently distinguish a disease that re- 
sults from some local and temporary cause, from one the 
causes of which are generally diffused, and pretty uni- 

Dd 



418 OUTLINES OF PATHOLOGY AND PRACTICE. 



formly recurring, — we observe, that all Idiopathic Fevers, 
Intermittent, Continued, and Eruptive, appear evidently 
to belong chiefly, if not exclusively, to the former class ; 
because they are all observed to prevail generally, and 
affect many persons in quick succession, in certain places, 
and at certain seasons ; and are almost or entirely ab- 
sent, for long periods, from other large communities, or 
from the same at other times. 

It is to be remarked, however, that continued Fever 
is on a footing somewhat different, in this respect, from 
Intermittent Fever, and from most of the Eruptive 
Fevers, or Exanthemata ; because although sometimes 
nearly absent, and not spreading epidemically, it can- 
not be ascertained to be ever completely absent, from 
any large community in this climate, for any consider- 
able length of time ; whereas the other diseases now 
mentioned, have been often known to be absent from 
whole kingdoms, and for centuries. This is a prima 
facie ground for suspecting, that the occurrence of this 
disease may be determined, on some occasions, by causes 
of more uniform and permanent existence than that from 
which it more generally proceeds ; and accordingly, it 
will afterwards appear, that we have probable evidence of 
its occurring in certain circumstances, independently of 
the application of contagion. 

Referring, again, to what was said before (p. GiyCtseq,) 
of the marks by which an epidemic disease, depending 
on a cause which arises from the soil, or is generated in 
the atmosphere in particular situations, may be distin- 
guished from one that is propagated by the intercourse 
of the sick with the healthy,- — we assert with equal con- 
fidence, that Intermittent and Remittent fevers are in 
the former predicament, and Continued fever, and the 



OF IDIOPATHIC FEVEE. 419 

Eruptive fevers in the latter. The experience of very 
numerous observers since the time of Lancisi has shewn, 
that fevers of the former class prevail only in certain 
localities, — that these localities resemble one another in 
certain respects,- — and that at a distance from these locali- 
ties all manner of intercourse of the sick with the healthy 
may take place, without a fresh case of the disease 
shewing itself. On the other hand, we are equally as- 
sured by very extensive experience, that all th'e facts 
formerly referred to (p. 66, et seq,\ as evidence of the 
occurrence of fresh cases of a disease being determined 
by the circumstance of intercourse with the sick, and 
being therefore referable to effluvia arising from the 
bodies of the sick, — are facts constantly observed as to 
the diffusion of continued fever, or of the eruptive 
fevers, through any community in which they become 
epidemic. 

It remains for us to state here, what has been ascer- 
tained as to the conditions under which these agents, 
known to us only by their effects, but so powerful in 
their action on the human body, are developed ; and as 
to the circumstances by which their activity is increased, 
and their effect on the living body variously modified. 

I. The whole conditions necessary to the develop- 
ment of the Malaria which excites Intermittent and 
Remittent Fevers in many parts of the earth's surface, 
(and to so great an extent, that no other single cause of 
mortality perhaps acts with equal effect), are certainly 
not known ; because the disease is found in some dis- 
: tricts, where, judging from the analogy of others, it 
\ would not have been expected; and is absent from others, 
t where all the conditions that are yet ascertained for its 



420 OUTLINES OF PATHOLOGY AND PRACTICE. 

development appear to exist ; but what is usually ob- 
served is, tbat the districts infested by it are those 
where water has stagnated for some time, often months, 
on the earth's surface, and afterwards slowly evaporated 
under the heat of the sun ; it is only after the evapora- 
tion is somewhat advanced that the disease shews itself ; 
and it often continues long, and with great virulence, 
' after the surface is perfectly dried. The putrefaction 
of animal or vegetable matter is, naturally, a very fre- 
quent concomitant of the process, by which the poison is 
thus developed ; but the facts stated by Chisholm,^ and 
FergTisson,-j- seem sufficient to shew that it is not an es- 
sential part of the process. 

The following general facts appear so well established 
by observation, as to be correctly designated as laws re- 
gulating the agency of this poison ; and the knowledge 
of these, as well as of the conditions of its development 
now stated, may often be effectual in preventing its ra- 
vages. 

1. Its ^^.rulence appears to be nearly in proportion to 
the intensity of the heat, by which the sm-face emittinof 
it has been dried. The Intermitting Fever of northern 
Europe, the Remitting Fever of the Mediterranean, and 
the Yellow Fever of the West Indies, are produced in 
circumstances in all respects similar, except as to the 
intensity of the heat ; the worst fevers of the tropical 
climates are nearly confined to a moderate elevation 
above the level of the sea ; and at the same time when 
they are prevailing in the low grounds, the common re- 
mittent fevers are often prevalent in the neighbourhood 

* See Edin. Med. and Surg. Journal, vol. vi. 

t On Marsh Poison. Edin. Phil. Trans, vol. ix. 



OF IDIOPATHIC FEVER. 



421 



of marshes a few hundred feet higher. The greater heat 
of certain seasons, and the more complete evaporation 
of stagnant water, seem to be powerful causes of the 
greater prevalence and malignity of fevers of this class ; 
but it must be allowed that unusually virulent epidemics 
occasionally occur, for which no such known cause can 
be assigned. 

2. The poison does not appear to diffuse itself readily 
through the air, nor to rise high above the surface emit- 
ting it ; the inhabitants even of the ground-floor of a 
house in a malarious district being often afi'ected in a 
much larger proportion than those of the upper stories. 

3. Although the heat of the sun appears to be one of 
the conditions of the development of the poison, yet its 
immediate effect on the poison that has been already 
evolved, seems to be to dissipate and dilute it, for it is 
much more dangerous to visit the most malarious spots 
at night than at noon-day. 

4. The poison appears evidently to be wafted along 
the earth's surface by winds ; for the disease prevails 
much more, where the trade-winds blow, to the leeward 
than to the windward of marshes. 

5. It appears to be absorbed or neutralized by passing 
over water, — ships having been observed to remain quite 
healthy within 1000 yards of shores, even to windward 
of them, where the disease was very prevalent. 

6. It appears to attach itself particularly to spreading 
trees, on which account woods and groves are particu- 
larly dangerous in malarious countries ; and again, when 
these intervene between a marsh and a town or village, 
they often appear to afford it protection. 

7. Its development, or its virulence, appears to be 
much diminished by the cultivation and habitation of 



422 OUTLINES OF PATHOLOGY AND PRACTICE. 



waste lands, even although they be occasionally flooded ; 
and it has often been found to increase suddenly and 
greatly, when fertile lands have been laid waste. 

8. It affects very differently the permanent inhabi- 
tants and the occasional visitors of the districts where it 
exists ; the former being generally weakly, imperfectly 
nourished, and short lived, but much less liable to the 
fever itself than the latter. 

9. In the hot climates there is an equally striking 
difference between the white and black varieties of the 
human race as to their liability to the effect of the ma- 
laria ; the blacks, even when healthy and robust, suffer* 
ing from it comparatively little. 

10. In all climates, this, like other causes of acute 
disease, acts with peculiar force on those whose bodily 
strength is at the time unusually depressed, whether by 
fatigue, intemperance, fasting, evacuations, or mental 
emotions ; and whatever measures are effectual in per- 
manently strengthening the system, are found the most 
useful in enabling it to resist this noxious influence. 

11. In those who have certainly imbibed the poison 
producing these fevers, it appears very generally to lie 
latent for a considerable length of time before the effect 
results. In some cases, in this climate, it is quite cer- 
tain that this latent period may not be less than nine 
months. 

12. What was formerly said of the frequent concur^ 
rence of the more general causes of disease, such as cold, 
intemperance, or any cause disordering the stomach, 
with the special cause of certain diseases, is strictly ap- 
plicable, as many observations prove, to the action of 
malaria in producing intermittent or remittent fevers ; 
and by the application of such causes, intermitting fevers 



OF IDIOPATHIC FEVER. 



423 



are often reproduced, more or less perfectly, in persons 
wlio have previously suffered from them, but have not 
lately been exposed to the malaria. 

In regard to the disputed question, Whether all the 
worst epidemic fevers of hot climates can be referred to 
the agency of this cause, or whether there exist occa- 
sionally in these climates fevers of peculiar malignity, 
which are propagated by Contagion, — it may be held to 
be established, that the cause of intermittent and remit- 
tent fevers does sometimes act with such intensity as to 
produce both a very unusual extension of disease, and 
all the worst symptoms, and the rapid and great mor- 
tality, of the most malignant form of fever ; and farther, 
that in by far the greater number of cases,* where ma- 
lignant epidemics, in the hot climates, have been suppos- 
ed to be imported from a distance, their origin has 
really been proved to be indigenous ; and must be as- 
cribed, therefore, to the unusual efficiency of the causes 
of fever previously existing in the districts. There is 
good reason to believe also, that even the worst epide- 
mic fevers of hot climates are always subjected to the 
same law as the common remittent fevers, of existing 
only within certain limits. 

But from all this it does not necessarily follow, that 
the extension of these epidemic fevers, or even that their 
origin, in certain spots, may not be the effect of conta- 
gion : For although it may seem improbable, a priori, 
that a disease should spread in two distinct ways, and 
although we may not expect, that one which results from 
a cause existing in the atmosphere, should also be pro- 

* See Chervin, Examen des Principes de 1' Administration en 
Matiere Sanitaire. Paris, 1827. 



424 OUTLINES OF PATHOLOGY AND PRACTICE. 



pagated, in part, by communicatiou between individuals, 
— yet no sucli speculative opinions can be allowed to in- 
validate the direct and obvious conclusion from facts (of 
wliicli several have been recorded), which indicate that, 
in some of the places where these epidemic fevers have* 
prevailed, those who have had close intercourse with 
the sick, have become themselves affected in a much 
larger proportion than others who, in all other respects, 
were similarly circumstanced. 

II. In resfard to Contaoion as a canse of continued 
fever, we shall first state what has been ascertained of 
the laws according to which the propagation of fever, 
by contagion, takes place (and which are found to apply, 
in some measure, to the other febrile contagious dis- 
eases) ; and afterwards we shall consider the question. 
Whether another origin can, in any circumstances, be 
assigned for these diseases ? 

1 . The extension of continued fever, in any commu- 
nity, is in general proportioned, as may naturally be 
expected, to the frequency and closeness of intercourse 
of the healthy with the sick, and therefore to the crowd- 
ing, and deficient ventilation, of the rooms which they 
inhabit ; but in difi'erent seasons, it takes place with 
very various rapidity, independently of the application \ 
of any causes which are known to affect it ; and from 
this varying diffusibility, as well as from the varying 
character and malignity of the disease (already noticed), 

it may be inferred that the contagious poison itself, as 
developed in the human body, is liable, from time to 
time, to a certain degTee of change. 

2. The contagious matter, arising from the bodies of 
the sick, appears to be readily diffused through the air, 



OF IDIOPATHIC FEVER. 



425 



and to lose its poisonous quality by dilution ; so that, at 
the distance of twenty or thirty yards, air which has 
passed over the bodies of persons ill of continued fever, 
is found to be innocuous. The contagious effluvia from 
smallpox, and perhaps still more from measles, appear 
to be more virulent than those from continued fever ; 
and it would appear that the poison of the plague, as 
arising from the bodies of the sick, is confined within 
narrower limits than that of any of these diseases. 

3. There is evidence, which to most inquirers has ap- 
peared satisfactory, of the contagious poison of continued 
fever (and of the eruptive fevers also), often attaching 
itself to fomites (clothes, furniture), &c. and acting on 
persons to whom it is thus applied at the end of weeks, 
or perhaps of months. 

4. It seems certain, that the Contagious Poison pro- 
ducing any of these diseases, is rendered innocuous by a 
temperature of 120° of Fahrenheit.* It has been ob- 
served, that intense atmospherical heat (though consi- 
derably below this point) has repeatedly checked the 
diffusion of plague, and of small-pox ; and the continued 
fever of this climate is very generally observed to abate 
in frequency in summer weather, and appears nearly in- 
capable of spreading by contagion within the tropics. 

5. Diseases proceeding from these contagious poisons 
differ from the fever excited by malaria in this import- 
ant particular, that the susceptibility of them is much 
diminished by their being once excited in the system. 
This does not confer certain immunity in the case even 
of the eruptive fevers ; and there are many cases of 
continued fever affecting the same person twice or even 



* See Henry in Philosophical Magazine, 1832. 



426 OUTLINES OF PATHOLOGY AND PRACTICE. 



thrice ; but there is certainly a great diminution of sus- 
ceptibility in all these cases. 

6. Young persons are certainly more susceptible of 
these contagious febrile diseases than persons advanced 
in life ; but the symptoms are very generally worse, and 
the tendency to spontaneous recovery is much less strong, 
in advanced than in early life. 

7. The susceptibility of the disease (in the case of 
continued fever in particular) is very much increased by 
many causes that depress the vis vitse at the time, by 
fasting or low diet, by cold long applied, by foul or vi- 
tiated air, and by mental depression, timidity, or anxiety, 
as in the case of besieged cities, communities suffering 
peculiarly from famine and poverty, beaten armies (espe- 
cially after the excitement of military operations is quite 
over); or in that of dispirited bodies of men for military 
or naval service, or of strangers from the country dur- 
ing their first residence in large towns. 

8. After any of these poisons have been imbibed, they 
very generally lie latent in the constitution for a certain 
length of time, before producing their specific effects ; 
and in the case of continued fever this time is so various, 
and the efficacy of concurrent and accessory causes 
(especially of exposure to cold) in exciting the disease, 
after the application of the contagion, is so obvious and 
striking, that it appears quite reasonable to suppose, that 
where these causes are carefully avoided, many cases of 
the disease, which would otherwise have occurred, may 
be averted. 

9. Although it must always be remembered, that there 
are great varieties, both as to individual cases, and as to 
the general character of epidemics, for which we can 
assign no cause, yet various facts have been ascertained. 



OF IDIOPATHIC FEVER. 



427 



as to the effects of concurrent or accessory causes, in not 
merely favouring the accession, but determining the form 
or variety, of continued fever in individuals, particularly 
the following. 

a. The Nervous or atactic form of fever (which is 
perhaps the most generally dangerous to adults in this 
country) is remarkably more frequent in those in whom 
the Nervous System has been recently much excited, as 
by much muscular exertion, by excessive study, by men- 
tal agitation or anxiety, by venereal excesses, or by in- 
temperance, especially the use of strong liquors. In 
many of this last class, the nervous symptoms in fever 
take very much the form of the Delirium Tremens of 
drunkards. 

h. The symptoms of fever are often modified by pre- 
ceding disease, and especially, if there has been recently 
any local inflammation, the symptoms of that local dis- 
ease are very often re-excited, although in a somewhat 
modified form. On the other hand, a chronic disease 
already -existing, at least if it be one which is attended 
with febrile excitement (such as phthisis) seems to be to 
a certain degree (although not uniformly) a protection 
against attacks of fever. 

c. The concomitant local affections, if not the proper 
symptoms of fever, are remarkably modified by the 
weather and season of the year, i, e. by the causes of 
local disease which are apt to take effect on the body 
along with, or after the application of, the poison. In 
winter and spring, the symptoms are stated to be gene- 
rally more inflammatory, and the complication of fever 
with bronchitis or pneumonia is certainly more frequent ; 
in autumn the concomitant affections of the stomach, 
and especially of the intestines, are chiefly observed. 



428 OUTLIXES OF PATHOLOGY AXD PRACTICE. 



Violent affection of the brain, in tlie more inflammatory 
form of fever, is remai'kably observed in hot climates, 
and sometimes in the hottest season of this. 

d. There is a remarkable difference in the most gene- 
ral form of fever, according as the patients are placed 
in cool -vrell-aired rooms, or confined in a close wann 
and vitiated temperature. It is very doubtful whether 
the mortality is so much less in the former case, as has 
been represented by some ; but in that case, the fever 
is generally less typhoid, and the danger more depen- 
dent on complication with local affections, and conse- 
quent protraction of the disease ; and in the latter case 
the typhoid symptoms are more frequent and urgent, 
but the duration usually less.* 

It has been already stated, that continued fever, al- 
though rare in some seasons, and prevaihng epidemically 
in others, is still, to a greater or less extent, so much 
more uniformly present in every large community, than 
any of the other diseases, which we ascribe to a local 
and temporary cause, that we may reasonably suspect it 
to originate occasionally from some circumstances of 
more general and permanent existence. And in confir- 
mation of this it may be observed, /?r5f, that continued 
fever often breaks out in situations where the application 
of the contagious poison, whether by persons or fomitis, 
not only cannot be traced, but appears improbable ; and, 
secondly^ that circumstances may be stated, in which the 
appearance of this disease, independently of any perce|>- 
tible application of contagion, may be reckoned on. with 
almost absolute certainty : e. a. the combination of defi- 
cient nourishment, foul air. and mental depression, con- 



* See Bateman on Contagious Fever, p. 135. 



OF IDIOPATHIC FEVER. 



429 



sequent on the reception of a beaten army into a small 
town, or on a large town long kept in a stage of siege, 
or on a scarcity befalling an already impoverished coun- 
try. In these circumstances it appears highly probable, 
that the circumstances of predisposition above stated are 
adequate, not only to the extensive diffusion, but even 
to the generation in a few individuals, of the disease 
which is afterwards propagated by contagion. But to 
which of these circumstances of predisposition, the occa- 
sional spontaneous origin of the disease may with most 
probability be ascribed, is still uncertain. The vitiation 
of the atmosphere by putrescent animal or vegetable 
substances, or by crowded human beings, has been sup- 
posed to be a sufficient cause, and the former of these 
opinions has lately been much espoused in England ; 
but so many instances have been collected by Dr Ban- 
croft, Dr Chisholm, Parent Du-Chatelet, and others, of 
both these causes being fully applied without any such 
effect ; and it is so easy to explain the frequency and 
peculiarly rapid diffusion of continued fever in the situa- 
tions where such effluvia exist, by the concentration of 
the contagious poison, and the other circumstances and 
mode of life of the inhabitants ; that we must set aside 
both hypotheses ; and perhaps we may assert that long 
continued mental depression and anxiety, during youth 
especially, has been assigned with more probability than 
any other cause, for the spontaneous generation of con- 
tinued fever.* 



* See Cheyne and Marsh in Dublin Hospital Eeports, vol. iv. 



430 OUTLINES OF PATHOLOGY AND PRACTICE. 



Sect. IV. — Of the Pathology of Ifliopathic Fevers^ 
and of their Fatal Terminations. 

Referring to what Avas formerly said of the Hmita- 
tions which Xatiire imposes on all explanations of na- 
tm-al phenomena, we hold it to be unreasonable to ex- 
pect, that we shall ever go far in explaining the peculiar 
phenomena of Fever ; we look chiefly for the determina- 
tion of ultimate facts or principles, relative to the action 
of its remote causes on the living body. 

The first question here is, whether the term Idiopa- 
thic be in reality correctly applied, or whether we can 
explain all the phenomena that have been now described 
by reference to a principle already explained, viz. the 
effect of local Inflammation in exciting the constitu- 
tional fever which was described, and the known varie- 
ties of which were considered. 

In treating of this question, we may, in the first 
place, refer to facts already stated^ as to the history of 
fevers. 

Taking for gTanted that what we have called Idiopa- 
thic Fevers may be distinguished, in almost all cases 
where their whole progress is observed, by the marks 
formerly enumerated (p. 391, et seq.), we regard all these 
circumstances in their history as aft or ding very strong- 
presumption, that they are specifically distinct from the 
strictly inflammatory diseases, and cannot be ascribed to 
inflammatory action as their cause. And the followino* 
considerations may be stated in farther confirmation of 
this doctrine. 

I. The peculiarities of the occasional and local pro- 



OF IDIOPATHIC FEVER. 



431 



duction, and application to the living body, of the ex- 
citing causes of these fevers, and of the characteristic 
depressing agency on vital action, which attends them, 
evidently assimilate, in some degree, this form of dis- 
ease to the agency of poisons. Now, it appears from 
what was stated formerly in regard to all such poisons 
as act gradually, and must be absorbed into the system 
before they take eflPect, that although they may excite 
local inflammation, yet they have always a general ef- 
fect, and usually a depressing effect, on vital action, 
whether of the nervous or vascular system, independent 
of that local agency. From this there arises a manifest 
presumption that the agency of malaria and of conta- 
gion, in producing fever, will in like manner be, in part 
at least, exerted on the system at large, and independ- 
ently of local inflammation, or mere alteration of the 
distribution of the blood. 

II. Although it is admitted that appearances indi- 
cating inflammation are very frequently found after fa- 
tal fever, yet the facts already stated as to the morbid 
anatomy of fever justify our maintaining, ^irs^, That all 
such appearances are sometimes absent ; secondly^ That 
the indications of inflammation, found in the different 
parts above enumerated after fever, are very generally 
somewhat different from those which are found after in- 
flammations of the same parts excited simply by cold, 
and unconnected with the peculiar symptoms of fever ; 
which implies the action, in cases of fever, of a peculiar 
cause, distinct from inflammation ; and, thirdly ^ That 
the appearances of inflammation, found after fever, are 
very often quite inadequate to explain the fatal event, 
on the principles formerly stated as to the fatal termi- 
nations of inflammatory diseases. 



432 



OUTLINES OF PATHOLOGY AND PRACTICE. 



It is plain that, in order to prove that fever depends 
essentially on, and is fatal by reason of, the attendant 
inflammation, it is necessary to shew, not only that such 
attendant inflammation exists, but that its nature and 
situation are such as to obstruct some function necessary 
to life, — or at least such as are found, in other cases, 
incompatible vrith life. If, therefore, we find after fatal 
fever (characterized, by typhoid symptoms), marks of 
inflammation in certain organs, but these in a degree 
much less than those which we are accustomed to find, 
where the same parts have been inflamed, but the cha- 
racteristic typhoid symptoms not shewn themselves, we 
are not entitled to infer that the inflammation in the 
former case was the cause of death. 

Now, the eftects and indications of inflammation, found 
after fatal fevers, and already described, are generally 
much less than what we are accustomed to observe in 
those cases of inflammation of the same parts, which are 
unconnected with malaria or contagion, and unattended 
with typhoid symptoms ; and frequently all that is seen 
indicates only congestion of blood, which can hardly be 
held to be a sufficient cause for death, if existing alone, 
anywhere but in the brain, or at the origins of the 
nerves. 

Even, therefore, where the evidence of inflammation, 
or irregular distribution of blood, having existed during 
fever, is held to be decisive, the proof of these having 
existed to a degree which can be reasonably considered 
adequate to the explanation of the fatal event, is very 
often essentiallv defective. 



- III. Xot only the fatal event, but the chief peculiari- 
ties of the symptoms, of the diseases described under the 
name of Idiopathic Fevers, are very often inadequately 



OF IDIOPATHIC FEVER. 



433 



explained by reference to any of the known phenomena 
and effects of inflammation. 

The different authors who ascribe fevers to inflamma- 
tion as their cause, are not agreed as to the organ in 
which that inflammation must reside ; which circum- 
stance is of itself a presumption against their common 
doctrine. But there is no locality which can be assigned 
to the inflammation attending fever, which can explain, 
by reference to the known effects of inflammation in 
other cases^ many of the typhoid symptoms of fever. 

The preternaturally fluid state of the blood, Avhich is 
very often, although perha^ps not uniformly observed, 
certainly cannot be explained thus. The enfeebled state 
of the circulation in typhoid fever has been thought by 
some to be sufficiently explained by the known sedative 
effect of inflammation of the intestines on the heart's 
actions ; but, besides that there are many cases of truly 
adynamic fever, where no distinct traces of intestinal in- 
flammation can be detected, the two cases are very dif- 
ferent ; — the depressed state of the circulation in cases of 
simply inflamed intestines being preceded by much more 
decided local symptoms than we see in fever, and being 
neither attended with the cutaneous heat of fever, nor 
with the eruption, nor with the foul dry tongue and lips 
of fever, nor with the nervous symptoms of fever, nor 
with the strong salutary tendency of fever. And al- 
though some of the symptoms produced by inflammation 
of the brain resemble the nervous symptoms of many 
cases of fever, yet in simply inflammatory cases, there 
are more sudden and violent attacks of pain, — there are 
very generally sickness and vomiting, — there is at one 
period of the disease slowness or irregularity of pulse,— 
the delirium is of a different character, — there is less 

E e 



434 OUTLINES OF PATHOLOGY AND PRACTICE. 



stupor in the early stages, and the stupor in the later 
stages is attended much more generally with dilated 
pupil, squint, blindness, or double vision, and is much 
more uniformly fatal, than in the fevers described as 
idiopathic. 

Farther, the appearances indicating inflammation, 
which are found after death by fever, are in many cases 
observed to correspond, not to any of the symptoms of 
the earlier periods of the fever, but to symptoms which 
presented themselves only recently before death ; so that 
the period of accession, as well as the nature and degree 
of the inflammation, that can be ascertained to exist 
during the fever, is inconsistent with the supposition of 
all the symptoms depending upon it. 

In farther proof that the characteristic symptoms of 
fever are not explained by the inflammations which may 
accompany it, we should observe, that there are various 
cases, formerly noticed, besides that now in question, in 
which inflammation is attended with typhoid fever ; e. 
the case of inflammation from an injury attended with 
violent concussion, the case of inflammation and puru- 
lent efl'usion in a vein, the case of inflammation from a 
poisoned wound, or from epidemic erysipelas, or other 
exanthematous disease, or puerperal fever ; and in every 
one of these it is obvious that the system is subjected to 
the influence, not only of a local inflammation, but also 
of a cause acting generally on the body, as we suppose 
the poison of what w^e call Idiopathic Fever to do. 

And if the local inflammation, which can be ascer- 
tained to take place during fever, is inadequate to ex- 
plain the characteristic typhoid symptoms, it is equally 
in vain to seek an explanation of these symptoms, as 
some have done, in the mere circumstances of irregular 
distribution and congestion of blood. 



OF IDIOPATHIC FEVER. 



435 



Even tlie peculiarities of tliat form of fever whicli has 
been described under the name of Congestive (p. 395), 
are not to be explained by the mere circumstance of in- 
ternal congestion, the existence of which, in the vessels, 
and especially in the veins of internal parts, in these 
circumstances is admitted. For although congestion or 
stagnation of blood within the cranium may be held to 
be a sufficient cause of stupor, yet we are so far from 
regarding congestion in the great veins leading to the 
heart as a sufficient cause for deficient action there, and 
consequent feeble pulse and cold skin, that we have al- 
ready stated (see p. 138) the accumulation of blood in 
the great veins to be apparently the chief cause of the 
increased action of the heart, or the reaction^ in the 
more usual form of fever. In the cases, therefore, where 
the congestion in the great veins fails to excite this re- 
action in the heart, some peculiar cause must have ope- 
rated to prevent the heart from being unusually excited, 
by the application of the unusual quantity of its natural 
stimulus; i, 6. the circumstance of unusually great and per- 
manent congestion in the great veins, in the commence- 
ment of fever, is in all probability the effect, not the 
cause, of a peculiar sedative influence affecting the vas- 
cular system in these cases ; such an influence naturally 
leading to accumulation of blood in the great veins, for 
the same reason that determines the accumulation there 
after death. 

That congestion of blood in the great veins is not per 
se adequate to account for the phenomena of any form 
of fever, appears distinctly from the fact, that no form 
of fever follows the great congestion there in cases of 
suspended animation in syncope, or from extreme cold, 
or submersion in water. 



43G 



OUTLINES OF PATHOLOGY AND PRACTICE. 



IV. That what we called Idiopathic Fever cannot 
justly be regarded as the effect of the inflammations 
often attending it, appears farther from a very sufficient 
experience of the juvantia and Icedentia^ particularly 
from what is well ascertained of the effect of evacuations 
on the one hand, and of stimulating remedies on the 
other, in this disease, as compared with the diseases that 
are acknowledged to be simply inflammatory. For after 
making allowance for the sources of fallacy necessarily 
attending such observations, we may assert that experi- 
ence has fully established the following points. 

1. That in the strictly inflammatory diseases, evacua- 
tions of blood are of the utmost use in the early stages, 
all other remedies comparatively inefficient, and stimu- 
lant remedies decidedly hurtful in all but the latest stage. 

2. That in the cases described as idiopathic fever, 
even although symptoms of local inflammation be pre- 
sent; the amount of evacuation which it is safe to prac- 
tise on account of these is much less than in the former 
case ; that its beneficial effect is less decided, — the local 
symptoms being seldom so effectually subdued, and the 
general, especially the typhoid symptoms, being seldom 
improved, and sometimes evidently aggravated by loss 
of blood ; that the tendency to a spontaneous favourable 
termination is much stronger ; and that even when in- 
dications of recent local inflammation exist, decided be- 
nefit may often be obtained from the use of stimulants, 
under which the pulse may improve, and the typhoid 
symptoms of general fever abate, without the local affec- 
tion being materially or even perceptibly aggravated. 

It is also ascertained by sufficient experience, that the 
inflammatory symptoms are more urgent, and evacua- 
tions in general much better borne in some epidemics of 



OF IDIOPATHIC I'EVER. 



437 



continued fever ; and that in others the indications of 
debility of the vascular system are more permanent, and 
stimulants more generally useful ; while no such differ- 
ences are observed as to the strictly inflammatory dis- 
eases in different seasons. 

These statements seem sufficient to shew, that it is a 
limited and hasty view of the phenomena and history of 
Fevers, which has suggested the opinion of their being- 
resolvable into the constitutional effects of the Inflam- 
mations, or local determinations and congestion of blood, 
which can be ascertained to attend them ; and that we 
may now safely apply the term Idiopathic as expressing 
the, belief of an essential distinction existing between 
these fevers, and those that were formerly described as 
resulting from local inflammation. 

At the same time, the strong similarity or coincidence 
in many respects of the essential symptoms of the symp- 
tomatic and the idiopathic fever, must always be re- 
garded as a leading fact in reference to the pathology 
of the latter. 

But in idiopathic fever, not only is a diseased action 
excited throughout the system, similar to that which 
local inflammation can excite, but the system is at the 
same time under the influence of a cause, which acts on 
it nearly after the manner of a Poison ; wliich we know, 
from the history of the disease, to be probably engeu- 
dered occasionally within the system itself, but to be 
most frequently absorbed from without ; and which 
takes effect, as poisons do, only for a time, and then 
loses its power. In regard to this morbific cause, which 
both excites and gives the peculiar character to the fe- 
brile actions, several questions present themselves. 



438 OUTLINES OF PATHOLOGY AND PRACTICE. 



I. It may be questioned whether tlie effect on the 
Nervous System, essential to fever, is produced directly 
by the external cause of fever, or whether that cause 
first works a change on the blood, and through its inter- 
vention affects the brain and nerves. 

It is plain that the blood is changed, at least as to its 
power of coagulation, in most cases, and probably it may 
be so in all cases of idiopathic fever. But a similar 
change as to that property may be produced in it, by 
causes acting in the first instance on the Nervous Sys- 
tem ; and this fact, therefore, does not indicate the part 
of the system which is primarily affected in fever. 

Reasons which appear, on fi^rst consideration of the 
subject, satisfactory, may be given against the supposition 
of many of the older pathologists, that fever essentially 
and exclusively consists in a certain change in the blood 
(quse prsssens morbum facit, sublata tollit, mutata mu- 
tat); in particular, two facts already stated, viz. 1. That 
after the morbific cause has been applied to the blood, it 
may depend, as we believe, on causes acting on the 
Nervous System only, whether or not it shall produce 
its specific effect ; and, 2. That even after that specific 
effect has been produced, and the febrile actions begun, 
they may, in a few instances, be arrested by means (such 
as the cold affusion) which neither evacuate any part of 
the blood, nor alter its composition. But when it is 
distinctly understood that the change in the blood, be- 
lieved to be morbific, is not in its chemical constitution 
simply, but in the vital qualities by which that constitu- 
tion is constantly regulated and maintained, these facts 
have not the weight against the humoral pathology of 
fever, which has been ascribed to them. 

At least it may be thought, that the remote cause of 



OF IDIOPATHIC FEVER. 



439 



fever does not produce its effect by merely once impress- 
ing the Nervous System, or otlier living solids ; but that 
it must necessarily affect for a time the fluids of the 
body, and perhaps multiply itself in them, in order that 
it may take effect on the solids. And in favour of this 
form of the humoral pathology of fever, the following 
facts may be stated. 

1. In a great majority of the cases in which we see 
typhoid fever, we are sure that some peculiar matter, 
generally absorbed from without, must be contained in 
the blood ; as in the case of fever from malaria, from 
contagion (whether of simple fever or the eruptive fe- 
vers) from inflamed veins, from animal poisons intro- 
duced by wounds, or from suppression of the natural 
excretion at the kidneys. That this peculiar matter, 
or the blood altered by it, should act like a ferment, as- 
similating much of the circulating fluid to itself, in the 
former case equally as in the latter, is quite in accord- 
ance with what has been observed, when purulent matter 
has begun to form in the blood. See Gulliver's Trans- 
lation of Gerber, p. 104. 

2. In all cases of idiopathic fever, as well as of the 
eruptive fevers, an interval, which is variable and often 
long, necessarily elapses between the application of the 
morbific cause, and the development of the fever ; which 
is easily understood on the supposition that a change is 
gradually wrought on the blood during that interval, 
but not on the supposition of the poison acting simply 
on the living solids. 

3. In a great majority of cases of typhoid fever, we 
know that a matter, similar in its effects on the human 
system to that which excited the disease, is ultimately 



440 



OUTLINES OF PATHOLOGY ANB PKACTICE. 



evolved in large quantity from the blood, making the 
disease contagious ; i. e. the morbific poison in one way 
or another is multiplied in the blood of the living body. 

It has been naturally supposed by pathologists at dif- 
ferent times, that the frequent and rapid abatement of 
fevers, after critical evacuations, is farther proof of the 
doctrine of their cause residing chiefly in the blood ; and 
that this morbific cause is really carried off by these 
evacuations. And in support of this opinion, it has been 
stated, that when putrid matters, or diseased secretions, 
have been injected into the veins of animals, and excited 
febrile symptoms, a peculiarly fetid diarrhoea has pre- 
ceded the recovery from these. 

But Avhen it is considered, 1. That copious or spon- 
taneous evacuations {e. g, of sweat) at the critical periods 
of fevers, often take place without the least good effect, 
if unattended by other marks of restoration of the natu- 
ral condition of the capillaries ; 2. That many fevers 
abate spontaneously and perfectly without crisis ; 3. 
That in all contagious diseases, morbific effluvia escape 
for a long time from, the body, without any good effect ; 
4. That there is no evidence of the critical evacuations 
possessing more contagious property than the effluvia 
which continually escape without advantage ; and lastly, 
that in smallpox in particular, experience has shewn, 
that the morbific matter in the pustules may be eva- 
cuated as quickly as it appears, without benefit, and 
may be reabsorbed into the blood without injury ; — we 
must think it doubtful whether the critical evacuations 
are the cause of the solution of the fever that succeeds 
them, or whether we ought not rather to regard them as 
the sign of the restoration of the natural state of the 



OF IDIOPATHIC FEVER. 



441 



vital actions in the capillaries of the body ; whereby the 
excited action of the heart is enabled to throw off an un- 
usual quantity of secretions and excretions, and then sub- 
sides ; because the cause confining the circulation, and 
therefore stimulating the heart, has ceased to operate. 

The doctrine of the existence of a morbific matter in 
the blood, therefore, is not established by the facts as to 
the critical evacuations, but must be rested on the other 
facts above stated. 

II. Whether the morbific cause first alter the fluids 
or not, it is evident that it affects the actions of all the 
living solids, whenever it excites fever ; and it may be 
questioned whether the first efi^ect of the morbific cause 
is exerted on the living action of Nervous or of the 
Vascular system. Besides what was formerly said on 
this point in treating of symptomatic fever (p. 139), the 
following reasons may be given for thinking that the 
Nervous System is much concerned in the changes oc- 
curring even from the commencement of fever. 

1. The nervous system is evidently more aflPected 
throughout the whole series of morbid actions, than in 
the former case, and the first symptoms by which the 
idiopathic fever can in general be recognised, are strictly 
affections of the nervous system. 

2. We have seen (p. 7), that when inflammation 
coexists in the living body, with the effect of a violent 
concussion of the brain and nerves, the fever that it ex- 
cites has often quite the typhoid character. 

3. We have good reason to believe, that changes tak- 
ing place unquestionably in the nervous system, viz. 
those which attend mental emotions of sufficient dura- 
tion and intensity, if they have not power (as it may 



442 OUTLINES OF PATHOLOGY AND PRACTICE. 



reasonably be conjectured, that in certain circumstances 
they have) to generate fever, have at least such an in- 
fluence on its causes, as to determine their efficiency or 
inefficacy in individual cases ; which is of itself a strong 
presumption in favour of the belief, that the primary 
action of these causes is on the nervous system. 

4. Besides these mental emotions, there are various 
other agents, formerly noticed as concurrent and acces- 
sory causes of fever, and by which we have reason to 
think, that the development of fever, after the poison 
has been imbibed, is often determined, — e. g, cold, mus- 
cular exertion, and intoxicating liquors ; and the chief 
action of all these causes also is on the nervous system. 

5. There is at least one remedy, of peculiar efficacy 
in counteracting the agency of one of the causes of fever, 
i. e, the Cinchona, which produces no visible effect on 
the vascular system, and the chief action of which, there 
is reason to believe, from what we see of it in other 
cases, to be on the nervous system. 

But whatever be the mode in which the morbific 
cause, in Idiopathic Fever, comes to affect the circula- 
tion, it is to the direct action of this cause, and not to 
the influence of any local diseased actions, excited in the 
body, that we must ascribe the enfeebled state of the 
circulation, — the altered state of the blood, — the pecu- 
liarly vitiated state of the secretions, — and, in a great 
measure also, the deranged state of the nervous system, 
— which were described as characteristic of Idiopathic, 
and especially of Typhoid Fever. 

And there is nothing inconsistent with what is known 
of the action of poisons, or of other agents on the ani- 
mal economy, in supposing that the morbific cause, after 
existing some time, and perhaps multiplying itself, in 



I 



OY IDIOPATHIC FEVER. 



443 



the fluids, may act simultaneously on the constitution 
of the blood, on the vital affinities in the capillary vessels, 
on the powers of the heart, and the vital actions of the 
brain and nerves. Indeed, if its first action be on the 
vital affinities, as formerly defined, it must necessarily 
affect nearly simultaneously all these parts. 

We have good reason to think, that it is especially by 
its action (whether direct or indirect) on the vital changes 
in the capillary vessels, that this cause excites the symp- 
toms which were described as characteristic of Fever ; 
and we refer to the account given of fever symptomatic 
of inflammation, for the explanation of the manner in 
which the different steps in the series of changes consti- 
tuting febrile action, consequent on that deficient vital 
action in the capillaries, are connected together. 

But the peculiar depressing action of the morbific 
cause on all the parts of the system above mentioned, 
appears ; from what has been said, to be perceptible 
throughout idiopathic, as distinguished from symptoma- 
tic fever ; and it is easy to understand, that its effect on 
any one of these may become so intense as to be dan- 
gerous. The sedative effect on the heart is often such 
as to enfeeble, and sometimes such as nearly to suppress, 
the febrile reaction, as in Congestive Fever ; that on the 
brain may produce fatal coma, as in some cases of Ner- 
vous Fever, independently of any effusion or organic 
lesion in the brain ; that on the vital functions going on 
in the capillary vessels may be such, and so long con- 
tinued, as to cause fatal inanition and exhaustion, as in 
some cases of Fever, fatal merely by reason of the long- 
endurance of the disease, without failure of the functions 
of any one organ in particular. All this is in accor- 
dance with what we see in cases where we know that 



444 OUTLINES OF PATHOLOGY AND PEACTICE. 



the blood is morbidly altered in constitution, particu- 
larly Isclfuria Renalis, or disease of the Kidneys. 

In most cases of fever, however, the danger is not 
produced solely in this way ; but appears manifestly 
owino^ to a comhination of the enfeebled state of the cir- 
culation, with peculiar derangement of the functions of 
individual organs, consequent on the attendant inflam- 
mations there, the symptoms and post-mortem appear- 
ances of which have been already described. In conse- 
quence of this combination, we have three distinct 
modes of fatal termination of fevers, which are often 
blended together, but in some cases are quite separate 
and easily distinguished ; and which are clearly illus- 
trated by the different kinds of sudden or violent death 
formerly described, — and by what has been said above 
of the morbid appearances left by fatal fevers. These 
are, 1. The death by Coma, referable partly to the pe- 
culiar action of the cause of fever on the brain, but 
partly also to increased determination of blood thither, 
or inflammatory action or effusion there ; 2. The death 
by A.sphyxiaj referable partly to the enfeebled state of 
the circulation, and want of power in the heart to pro- 
pel the blood through the lungs, but partly also to Bron- 
chitis or Pneumonia, 3. The death by mere Asthenia^ 
referable partly to the deleterious effect of the morbific 
cause on the circulation, but frequently also, in part to 
various local inflammations, prolonging the febrile state ; 
and especially to the inflammations and ulcerations in 
the mucous membrane of the intestines, which appear to 
have in this, as in other cases, a peculiar sedative, and 
what was formerly designated as a sympathetic, effect 
on the heart's actions. 

It was already stated, that these inflammations during 



OP IDIOPATHIC FEVEE. 



445 



the state of fever, are so far influenced by the altered 
condition of all vital actions in the capillary vessels at 
that time, that the local effects which they produce differ 
materially from those which follow inflammation of the 
same parts in a system free from general fever ; — as is 
seen, e, g. in watching the progress of a parotid, or other 
external abscess, commencing during the febrile state, 
but only suppurating fairly when that state has subsided. 
Nevertheless, the internal inflammations often attendino- 
fever are quite sufficient, when their effect is combined 
with the generally enfeebled state of the circulation, to 
cause great danger. 

The nature of the connexion between these local in- 
flammations and the general fever is often obscure. In 
many cases, especially when the bronchiae and lungs are 
affected, early in fever, they are evidently produced by a 
different cause (chiefly cold applied before the onset, or 
during the course of the disease), and only accidentally 
combined with the fever ; but in other cases they may 
probably be regarded as effects of the general fever. The 
determination of blood to the head, and consequent slight 
inflammation and effusion, seem often to be of this de- 
scription, and are analogous to what sometimes happen 
in inflammatory diseases of other organs than the head. 
The peculiar condensation of the lowest portions of the 
lungs, in the later stage of fever, and its distinction 
from true hepatization, were already considered. The 
reproduction in any part of the body, of inflammatory 
action which has recently subsided there, appears to be 
an effect, rather than a mere accompaniment of fever. 
'And the peculiar inflammation of the mucous glands 
and membrane of the intestines, when it takes place 
late in the disease, may be suspected to depend very 



446 OUTLINES OF PATHOLOGY AND PRACTICE. 



mucli on the bile, and other irritating^contents of the 
intestinal canal, passing over a membrane, which, in 
consequence of the feeble circulation, the blunted sen- 
sation, and the deficient secretion, has lost much of 
its natural protecting mucus ; and- resting longest on 
that portion of the canal where we know that, from the 
action of the ileo-coecal valve, there must be a delay of 
the foeces ; and to be analogous to the inflammation of 
other mucous membranes, consequent on section of their 
sensitive nerves, — and to that which precedes death by 
starvation. 

On this supposition, inflammations of the mucous mem- 
brane of the intestines, occurring towards the close of 
protracted fevers, will stand in nearly the same relation 
to them as the inflammation, ulceration, and gangrene, 
from pressure on external parts ; which are very com- 
mon, and often constitute a great part of the danger in 
such cases. 

These relations between idiopathic fever and the con- 
comitant local inflammations are of great practical im- 
portance; and the chief difficulty and nicety in the 
treatment of fever, lies in determining, how far the dan- 
ger depends on such local affections as demand evacua- 
tions, and how far on the effect produced on the system 
by the morbific cause, which will often spontaneously 
abate, and often demands remedies of the opposite class. 

An opinion has lately become rather prevalent, that 
there are two kinds of Fever, to which the names of 
Typhus, and of Typhoid Fever, have been given, of which 
the first is usually unconnected with any affection of the 
mucous membrane, is attended with the eruption, and is 
more contagious ; the latter is necessarily connected 



OF IDIOPATHIC FEVER. 



447 



with inflammation going to ulceration of the mucous 
membrane, is unattended with eruption, is more pro- 
tracted, and has httle contagious property. This term, 
Typhoid Fever, is to be regarded as synonymous with 
Gasti'o-Enterite^ and with Dothinenterite. If it be un- 
derstood that the intestinal inflammation in this last case 
is of specific character, this doctrine can have no inju- 
rious practical results ; but it is certain, that some cases 
resulting from the contagion of the usual spotted typhus 
shew all the symptoms and post-mortem appearances 
attributed to the typhoid fever ; and therefore it seems 
most probable that the differences observed are only 
varieties depending on constitution, and on the agency 
of other causes affecting the constitution, besides the 
exciting cause of the disease. 

It may be judged, from what has been stated, that 
the Prognosis in the Continued Fever of this country 
must depend, partly on the nature of the prevailing epi- 
demic, partly on the intensity and endurance of the pro- 
per typhoid symptoms, and partly on the degree of com- 
plication with local disease. The whole mortality of 
patients admitted into the Infirmary in Edinburgh has 
varied of late years from 1 in 25 to 1 in 6 ; the later 
Epidemics being the most mortal ; but it is seldom 
much below 1 in 10. The mortality among cases not 
admitted to the Infirmary (as these are chiefly children) 
is, however, less than this. 

The following are important observations to be made 
as to the Prognosis in Continued Fever : — First, That 
the mortality from it is least in early life, and gradually 
increases as life advances, so that below the age of ten 
it is often as low as 1 in 30 or 40 ; and above the age 



448 OUTLINES OF PATHOLOGY AND PRACTICE. 



of forty it is usually 1 in 3, or even 1 in 2 f secondly, 
That the mortality from it is greater, in all ranks of 
life, beyond the age of puberty, in men than women ; 
thirdly, That it is greater, beyond that age, in persons 
of the higher ranks of life, than of the lower ; and 
especially in those persons of the higher ranks who have 
been accustomed to much exertion of intellect, or suf- 
fered much anxiety of mind. 



Sect. V. — Of the Treatment of Idiopathic Fever. 

What is to be said on this subject is applicable, with 
very little variation, to the treatment of all the febrile 
diseases, strictly so called, i. e. of all those fevers which 
we believe to depend on the action of a morbific poison 
introduced into the body, and which, in the present 

* In a recent elaborate inquiry by Mr Watt, into the mortality 
of different great towns in Scotland for some years, a remarkable 
uniformity was observed as to the proportion of recorded deaths 
from fever, falling on the different periods of life ; and as the great 
majority of fever patients are in the early periods of life, this ob- 
servation confirms what is stated above. 

Of the whole deaths from fever, at the following towns, the pro- 
portions falling on the different ages stated were as follows — 

Under 10. 10 to 20. Above 20. 

Edinburgh, . . 12 per cent. 29 per cent. 70 per cent. 
Glasgow, . . 12 ... 29 ... 70 ... 
Perth, . . 15 ... 30 ... 69 ... 

Dundee, . . 19 ... 51 ... 48 .:. 

The greater mortality early in life at Dundee is probably owing 
to more numerous cases of affection of the bowels, which complica- 
tion is most frequent in youth. 

a 



OF IDIOPATHIC FEVER. 



449 



state of our knowledge, we have no means either of 
expellmg, or of depriving of its noxious power. 

It is obvious, that in undertaking the treatment of 
any such disease, we must keep constantly in view those 
provisions of Nature, hitherto imperfectly understood, 
by which the operation of these morbific poisons is 
rendered transient, and to which we therefore trust for 
recovery from their influence, after a given time ; pro- 
vided that, during that time, the functions essential to 
life can be preserved from serious injury. To these 
provisions, all that art can do in these diseases, in the 
present state of our knowledge, must be held to be sub- 
servient and auxiliary ; but we know that these provi- 
sions require a certain, often definite time, and cannot be 
accelerated, as those on which the resolution of inflam- 
mation depends may often be, by art ; and although it 
is true, as stated by Cullen, that " the operations of 
Nature are precarious, and not so well understood, as to 
enable us to regulate them properly," yet observation of 
the natural course of these diseases enables us to judge, 
with considerable precision, both of the circumstances 
in which the favourable result of these operations is to 
be expected, and of the causes which often frustrate their 
good eff'ect ; and in many cases we have good reason 
to believe, that our remedies may successfully oppose 
the action of these causes. 

Taking this view of the agency of remedies in these 
diseases, we can easily perceive the correctness of the 
statement of Cullen, that the object of practice in them 
is, to " obviate the tendency to death," — L e. to oppose 
those of the series of morbid changes, occurring during 
the disease, by which the fatal event, in any individual 
case, appears likely to be brought about. These imme- 

Ff 



450 OUTLINES OF PATHOLOGY AND PEACTICE. 



diate causes of death may be distinctly perceived to be 
very various in different cases of disease, wliicb spring 
from the same contagion, and shew the same unequi- 
vocal distinctive marks; and they are susceptible of illus- 
tration, by reference to the cases of sudden and violent 
death, and likewise to the fatal termination of inflamma- 
tions of different parts. 

Our knowledge of the essential nature of febrile ac- 
tion does by no means entitle us to acquiesce in the 
statement of Cullen, that our method of treatment in 
Fevers "may be directed by a proper attention to the 
proximate cause of Fevers,'' but we hold that it ought 
to be directed /zr5#, by knowledge of the natural progTess 
and decline of these diseases, and of the symptoms which 
indicate that course; and, secondly^ by knowledge of 
the nature of those changes, and those complications, 
occurring in many individual cases, which appear to 
alter the natural progress towards recovery, and de- 
termine the fatal result. 

Our first object is, to place the patient in circum- 
stances favourable to the ultimate decline of the disease, 
by withdrawing him from the operation of those causes 
which are known by experience to aggravate the febrile 
state, i, e. by the Antiphlogistic Regimen. Those parts 
of this regimen which consist in removing the irritation 
arising, 1st, from strong impressions on the external 
senses ; 2^/, from voluntary exercise of body or mind ; 
and, 3c/, from the taking in of aliments, — are proper to 
be observed during the whole period of febrile action. 
Rest and quiet are to be strictly enjoined, the irri- 
tating influence either of heat or cold to be avoided, 
and a moderate grateful temperature secured, thirst to 
be allayed by full allowance of mild liquids, and the 



OF IDIOPATHIC FEYEK. 



451 



action of the bowels watched, and full daily evacuation 
of fseces secured by medicines, or enemata, when re- 
quired. We have many opportunities of observing, 
that those in whom these precautions are neglected in 
the early part of the disease, usually have it in an ag- 
gravated and complicated form. 

The free admission of pure air may be easily be- 
lieved to be beneficial-; but we see the disease so fre- 
quently run its course quite favourably in very foul and 
close air, that we cannot suppose this to be of the im- 
portance to the progress of the disease in individuals, 
which has been supposed ; and it certainly often ap- 
pears, when a patient has lain in a warm and close 
room during a considerable part of the disease, that the 
change to cool and fresh air (particularly if accom- 
panied with some muscular exertion), has an injurious 
effect, chiefly in bringing on a complication of local in- 
flammation. 

It is then to be remembered, that when patients are 
placed in the circumstances above stated, a great ma- 
jority of them, in most epidemics, especially if young, 
and previously healthy, will pass through the disease 
favourably without any farther treatment ; and that 
powerful remedies, of any kind, may materially injure 
the course of the symptoms that is to be expected; 
therefore, that we should see clearly before us, some 
change that is likely to be injurious, and some remedy 
fitted to counteract it, — and should look forward, be- 
sides, to the eflect to be expected from that remedy on 
the ulterior progress of the symptoms, before determin- 
ing on farther interference ; excepting only by such pla- 
cebos as may seem necessary for the satisfaction of 
patients or their friends. 



452 OUTLINES OF PATHOLOGY AND PRACTICE. 



Next, we should attend to what has been observed as 
to the nature of the prevailing Epidemic, particularly 
as to the circumstances in v/hich death has been chiefly 
observed, and the symptoms immediately preceding it, 
and likewise as the effect, either of depleting remedies 
on the one hand, or stimulating remedies on the other, 
on the progress of the symptoms. For it is quite cer- 
tain that in some epidemics, most of the fatal termina- 
tions are observed to be preceded by coma, or by dys- 
pnoea, with pretty full pulse almost to the last ; and 
that in others there may be few fatal cases preceded 
by coma or urgent dyspnoea, — or at least few, in which 
these symptoms are not attended by such feebleness 
of the circulation, as obviously in itself implies great 
danger ; — that in some epidemics, the strength of patients 
may often be observed to sink under evacuations which 
are usually well borne in others ; — again, that in some 
epidemics, stimulants are taken largely, without any 
injurious effect on the symptoms of affection of the 
brain, — while in others, increasing delirium and stupor 
seem generally to follow their use. 

The expectation of cutting short fever, by the use of 
any powerful remedies in the first few days, must be very 
slight ; we know that all the remedies, usually recom- 
mended for that purpose, are very frequently employed, 
even from the commencement, without any perceptible 
effect on its duration; and we meet with so many cases 
of Ephemeral Fever, — z. e. of febrile attacks of a day or 
two's duration only, in persons of irritable constitution, 
and in those who have been fatigued and exhausted by 
nursing friends, and been thought likely to imbibe conta- 
gion, that we can perceive an obvious source of fallacy in 
regard to cases thought to have been cut short. Never- 



OF IDIOPATHIC FEVER. 



453 



tbeless it is right to mention, that the means by which 
this object has most frequently seemed to be accom- 
plished are, a small bleeding, followed by such a com- 
bination of purgative medicine, with Tartar Emetic, as 
has produced vomiting, purging, and sweating, within 
a short time. In some instances the Emetic alone has 
seemed effectual, but probably only when sweating took 
place, and was encouraged after it. 

When a case is seen from the commencement, while 
the rigors continue to recur, and the patient is of such 
habit of body, and the strength of circulation such, that 
the subsequent progress of the disease may be expected 
to be improved, rather than injured, by these evacua- 
tions, it is right to use them at this early period, and 
with this view; but it is always to be kept in mind, that 
the disease will most probably go on, and that although 
the first uneasy sensations be relieved, its subsequent 
course may be very various. 

It is important to observe, that in this early stage, 
the effect of a small bleeding, taken in the erect pos- 
ture, is often to produce faintness ; this is often impor- 
tant as a criterion of the nature of the disease, and 
likewise as an indication of the quantity of blood which 
can be safely drawn. In some instances the affusion of 
cold water, immediately after the febrile reaction, or 
hot fit of fever has set in, has seemed to cut short the 
disease ; but although that remedy, in the early part of 
the disease, seldom fails to cause great reduction of the 
frequency of pulse and heat of skin, and to relieve the 
most uneasy feelings, it is very generally found, that 
these advantages are only temporary, and that the sub- 
sequent progress is not materially altered ; and although 
the repetition of the remedy is quite safe, when the 



454 OUTLINES OF PATHOLOGY AND PRACTICE. 



pulse is firm and skin is permanently hot and dry, and 
no indication of inflammation or congestion of blood in 
any internal organ exists ; yet in tlie much greater 
number of cases of severe fever, in which some such 
local indications exist, experience has shewn, that the 
check thus given to the circulation on the surface, and 
particularly on the extremities, is attended with very 
considerable risk of aggravation of the local affection. 

More frequently we see a patient in fever only after 
the reaction has been completely established, and have 
no expectation that its course can be materially or safely 
shortened by remedies. In such a case, we can hardly 
regard it as an object to moderate the general febrile re- 
action, by active treatment, on account of danger from 
that cause alone, because we know that the mortality of 
the disease is least in those patients in whom the fre- 
quency and strength of pulse, and heat of skin, are 
greatest in the early stage ; but in so far as we can 
perceive that there is local disease, approaching to in- 
flammation, which is aggravated or kept up by the 
strength of the reaction, we are justified in using the 
means of reducing it to what we regard, from habitual 
observation, as a moderate febrile reaction, — with a view 
to the mitigation of that local affection. 

1. When we have more than usual of pain of head, 
— throbbing of the temples, — -impatience of light and 
sound, — restlessness, — pervigilium, or active^ delirium, 
early in fever, — we look forward to the prospect, cer- 
tainly realized in some such cases, of death by coma, 
before the end of the second week, — the pulse conti- 
nuing full and firm, and the skin warm, almost to the 
last ; and we know that these symptoms may probably 
abate considerably after a bleeding at the arm ; we 



OF IDIOPATHIC FEVER. 



455 



have the less apprehension about this step if the pulse 
be firm, and not very frequent ; and we know, also, that 
in certain epidemics, the danger above stated has been 
frequent, and even repeated bleeding, to eight, ten, or 
twelve ounces, to moderate these symptoms, has been 
well borne — no failure of the strength of the circulation 
succeeding, and the mortality under that practice being 
small. But we know, also, that in most epidemics, the 
danger, as indicated by the symptoms immediately pre- 
ceding death, is considerably different from this ; that 
although death may take place in the way of coma, it 
is not, in general, until the circulation has already been 
for some time so feeble in itself as to indicate great 
danger ; that the pulse has often rapidly sunk in strength 
after bleeding ; and that the mortality among those bled 
early in the disease, has been observed to be unusually 
great. We know, likewise, as already stated, that al- 
though such effusion in the cranium, as we may believe 
to be inflammatory, does occur in fever, yet it is almost 
always slight, and may be altogether absent, even when 
death takes place strictly in the way of coma. There- 
fore, in general, we think it best to moderate the violence 
of reaction, and lessen the danger of increased determi- 
nation to the head by other less debilitating means ; of 
which the following are the chief, and the use of which 
must be regulated, partly by the intensity of the local 
symptoms — partly by the strength of the circulation. 

1. Local Bloodletting by leeches, of which twelve, 
applied twice to an adult, may be considered full evacua- 
tion in this way, in most epidemics of fever. 

2. Purging (if there be no spontaneous diarrhoea), so 
as to produce fluid evacuations ; and if this is to the 
extent of three or four daily, during three or four of the 



456 



OUTLINES OF PATHOLOGY AND PKACTICE. 



days of tlie first week, this remedy may be said to have 
been fully employed, though there are many cases in 
which the head is much affected, and the pulse firm, 
where more than this is done safely, and apparently with 
good effect. 

3. Shaving and cold washing of the head, and occa- 
sionally of all the upper part of the body, sometimes even 
the cold affusion, with the precautions that may be under- 
stood from what is stated above. 

4. The use of small, slightly nauseating doses of 
Tartar Emetic, repeated once in two hours. 

5. Some expedients which may be said to act as de- 
rivants from the head, are also useful in the restlessness 
and delirium of the early stages, — particularly warm 
fomentations, — the pediluvium, — the erect posture re- 
peatedly assumed for a short time, and stimulating Ene- 
mata, such as that with Turpentine. 

Small doses of Saline medicines, especially if given 
in the state of effervescence, are grateful to the patient, 
and have been thought to take effect on the febrile 
state ; but we cannot suppose that they do so by their 
diaphoretic power ; for during the greater part of the 
disease, sweating is hardly to be produced by drugs, and 
when taking place spontaneously, is followed by no good 
effect. 

After the uneasy feelings in the head have been re- 
lieved by more or less of this antiphlogistic treatment, 
in the first few days of fever, it is very often found, 
that a moderate dose of an opiate at night, sometimes 
followed by a second smaller dose, procures sleep, and 
gives much relief to the feelings of the patient. With- 
out such previous preparation, the effect of opium on 
the state of the nervous system is often unfavourable. 



OF IDIOPATHIC FEVER. 



457 



and even after it, its effect is by no means uniform, — 
apparently much influenced by individual constitution, 
— generally more certain in persons of the lower than 
tbe higher ranks ; but in many cases where delirium is 
apprehended from the persistence of the wakefulness 
and restlessness, its use is followed by sleep, and more 
tranquil feelings, without stupor ; and after two or three 
nights, it may be withdrawn without the restlessness re- 
turning. 

When the pulse is frequent and full, and active de- 
lirium present, even after the evacuations, the opiate, 
in rather smaller and repeated doses, is given most 
safely along with Tartar Emetic ; or repeated nauseat- 
ing and purging doses of the Tartar Emetic, may pre- 
cede any trial of Opium. As the disease advances, 
there is more danger of stupor, particularly in those 
who have had much delirium, and the opium should be 
withdrawn, or given with much caution ; but in some 
it is useful, after some evacuation, and along with the 
Antimony, on the accession of more violent delirium, 
even late in the disease. 

When there is much tremor and spasm in the ad- 
vanced stage, the opiates, or Camphor, without the an- 
timony, sometimes appear distinctly useful, — provided 
the spasms are unattended by any comatose tendency; but 
full doses of narcotics at this period are always hazard- 
ous ; and the effects of all should be carefully watched. 

The comatose tendency in fever, whether gradually 
advancing, or more quickly succeeding to delirium, 
when not too far advanced, may often be successfully 
opposed by blistering on the head, and by purgatives, 
especially aided by stimulating Enemata ; but drowsi- 
ness, from which the patient can easily be roused, re- 



458 OUTLINES OF PATHOLOGY AND PRACTICE. 

quires no active treatment, and is to be regarded as fa- 
vourable. 

2. In the complication with Bronchitis, or threaten- 
ing of Pneumonia early in fever, the local bleedings 
(chiefly on the breast), — the Antimonials, or slightly 
nauseating doses of Ipecltcuanha, and the opiates in 
smaller doses than in the former case (lest they interfere 
with expectoration), but pretty frequently repeated, — 
and then blisters to the chest,— are the chief remedies. 
The blisters, particularly in children, should be kept 
on only a few hours, and vesication promoted by poul- 
tices, lest ulceration or sloughing should succeed. 

The chest affection, which is combined with the early 
stage of fever, usually subsides under this treatment ; 
that which comes on gradually and insidiously in the 
later stages is more dangerous ; and the death, if not 
strictly by Asphyxia, certainly preceded, and partly 
caused, by urgent dyspnoea, by no means uncommon. 
This complication may often, however, be mitigated by 
more or less of the remedies now mentioned, and by 
expectorants, gradually made more stimulating, par- 
ticularly by the addition of Ammonia ; and it is to be 
observed, that if it remains pretty stationary for a few 
days, — much cough and dyspnoea, although obviously 
prolonging the disease much beyond its usual period, — 
may often be gradually but completely recovered from, 
without active treatment, provided the circulation re- 
mains of tolerable strength. This remark applies par- 
ticularly to fever occurring in persons who are consti- 
tutionally liable to chronic bronchitis and asthma. 

The symptoms which chiefly indicate that the time 
for the antiphlogistic treatment is over, and that the 
stimulating only is admissible, are feeble pulse, — cold- 



OF IDIOPATHIC FEVER. 



459 



ness of skin, — lividity and general sub-crepitous, and 
mucous rale. As we know that there is mncli ten- 
dency to serous effusion in the lungs in these circum- 
stances, there is an obvious indication for diuretics ; e. g. 
Squill, Digitalis, and Calomel ; but these must not be 
given in such doses as to interfere, by their nauseating 
or depressing effect, with the main object of keeping up 
the strength of the circulation. 

The dyspnoea which comes on only in the last stage 
of Fever, with little or no cough, with a feeble pulse, 
and often with strong tendency to coma, is very gene- 
rally a fatal symptom ; it may be presumed to depend 
on the congestion of blood in the depending parts of 
the lungs, formerly noticed, as a natural effect of de- 
bility, particularly if any bronchial inflammation is pre- 
sent; and is not a case for any kind of evacuating 
treatment, excepting in a few incipient cases, where it 
seems to be partly dependent on insensibility, and to 
be relieved by blistering the head and stimulating ene- 
mata. 

3. There is often, in the early stage of Fever, par- 
ticularly in summer and autumn, pain and tenderness 
at stomach, occasionally slight yellowness of skin and 
eyes, and sometimes much vomiting ; which may be 
relieved by leeching on the stomach, — by purgatives, es- 
pecially those containing Calomel, if the stools are un- 
natural, and (especially the vomiting) by a blister on 
the Epigastrium. Sickness and vomiting at a more ad- 
vanced period, often seem to depend on complication 
with a more chronic, or even organic affection of the 
stomach or liver, and are sometimes relieved by small 
doses of Calomel with Opium, or by Enemata contain- 



460 OUTLINES OF PATHOLOGY AND PRACTICE. 



ing small quantities of Morphia ; but sometimes they 
are associated, especially in older persons, with the co- 
matose tendency, forbidding the use of Opium. 

As the disease advances, we must watch the state of 
the bowels, particularly in younger patients, for in- 
dications of the characteristic affection of the mucous 
membrane, which are unfortunately often very obscure ; 
— suspecting it always, if the bowels are naturally loose, 
and the disease appear protracted, and especially if the 
diarrhoea is attended with griping pains, or distension 
of the abdomen; and by no means expecting that it 
will shew itself, either by tenderness of the abdomen, 
or by discharge either of blood or mucus by stool. We 
know that in many cases, particularly if there be the 
griping pain and beginning distension, leeches applied 
to the abdomen in such circumstances, are followed by 
a distinct abatement of the symptoms, and apparent 
shortening of the disease ; and whether with or without 
the leeching, we can very generally observe, that re- 
peated small doses of Opiates, with Acetate of Lead, or 
with the vegetable astringents, or given in Enema, are 
followed by abatement of the number of stools, and im- 
provement of all the symptoms. These are less likely 
to be injurious, as in these cases there is generally little 
of the comatose tendency ; but they should not be used 
in such quantity as suddenly to check the diarrhoea, or 
to prevent full daily evacuation of the bowels. 

When the distended state of the abdomen continues, 
without diarrhoea or after its abatement, it may some- 
times be successfully obviated by astringent and stimu- 
lating Enemata, as by those containing powdered bark 
or Quinine with Assafoetida, and by small doses of laxa- 



OF IDIOPATHIC FEVEK. 



461 



tives and astringents (as Rhubarb with Quinine) given 
by the mouth. 

But while we watch the local symptoms occurring in 
fever, with a view to the use of these remedies, we must 
likewise attend carefully to the indications of the state 
of the circulation, because we know that there are cases, 
of the adynamic form of the disease, which are fatal 
by mere Asthenia, without any of these local affections 
existing in a degree perceptible, either before or after 
death ; and that generally even in the complicated 
forms of fever, a great part of the danger depends on 
the enfeebled state of the circulation; we know, both 
from dissections, and from experience of the juvantia 
and leedentia, that there may be coma, dyspnoea, and 
diarrhoea in fever, — all depending on causes which no 
evacuating remedies can relieve, and which may never- 
theless spontaneously and finally abate ; and we know, 
farther, that a great degree of all these symptoms may 
exist in fever, and be gradually recovered from, if coex- 
istent with a tolerably firm pulse, and vigorous circulation 
on the surface of the body, as indicated by the persistence 
of the heat. We therefore do not urge the use of Evacu- 
ations for the local affections in fever, as we should do 
in cases of idiopathic inflammation of the same parts ; 
and whenever we observe the circulation to become 
feeble, — or even (in Epidemics where we know that 
much debility is to be expected, before it has become 
feeble), — we use the stimulants, — chiefly wine, — in bad 
cases, spirits, ammonia, or aether, — in small but fre- 
quent and gradually-increasing doses, — both during and 
after the time when the remedies are applied to the 
local affections, — in the hope of maintaining the requi- 
site strength of the circulation, until the time when the 



462 OUTLINES OF PATHOLOGY AND PRACTICE. 



spontaneous favourable change is to be expected : and 
althougb many of tlie cases, in wliicli the circulation 
becomes very feeble, are fatal, we see many recover, 
both from the simpler and more complex forms, to 
whom the stimuli are given in such quantity as cannot 
be supposed to be inert ; and in whom the pulse becomes 
less frequent and firmer under their use, and therefore 
the most dangerous part of the disease undergoes im- 
provement, — even before any distinctly favourable 
change of any other symptom takes place, — and this 
without any aggravation, or even with simultaneous 
abatement, of the local ajBPection. It is perhaps chiefly 
in cases protracted somewhat longer than usual, that 
we see especial advantage from the stimulants. 

In the later stages, there is not only much sufi'ering, 
but occasionally danger, from the inflamed, ulcerating, 
and sloughing parts of the skin, on which the patient 
has chiefly rested, which may often be, to a certain de- 
gTce, prevented by the air-pillow, or other expedients, 
for relieving the sacrum or hips from the pressure. 
When these sores exist, they are benefited by gently 
stimulating or astringent, chiefly spirituous, applications 
at first ; followed by poultices, and often by hot dressings 
when sloughing has begun, and by astringent and slight- 
ly stimulating lotions after the sloughs have separated : 
no healthy granulations can form as long as the truly 
febrile state continues, but the rapidity of the healing 
process, after the febrile action has subsided, is often 
surprising. 

It is always important to watch the very commence- 
ment of convalescence from fever, on account of the 
facility with which relapse may be produced by exertion, 
exposure to cold, or errors in diet ; and likewise because 



OF IDIOPATHIC FEVER. 



463 



of the frequency of insidious, nearly latent inflamma- 
tions, — particularly in the chest, which often succeed so 
quickly, that their symptoms are easily mistaken for 
the proper symptoms of the fevers ; but which may 
often be distinctly recognised, and successfully opposed, 
by such depleting remedies as would have been dan- 
gerous only a few days previously. 

In the case of the Remittent Fevers of hot climates 
or seasons, the practice must be of the same general 
character as in the continued fevers of this climate, 
and requires at least as much to be modified, according 
to the nature of the prevailing epidemic. In some sea- 
sons, the symptoms resemble those of inflammation of 
the brain, stomach, or liver, and full and repeated blood- 
letting, and free purging, are well borne, especially by 
Europeans, lately arrived in tropical climates ; but in 
other seasons, and particularly in those when the dis- 
ease is most prevalent and most fatal, the symptoms 
are more typhoid, or the patient is soon exhausted by 
vomiting, ultimately black vomiting ; and in such sea- 
sons, generally, evacuations are much worse borne. 
Whatever remedies appear to be demanded, either by 
the state of the circulation, or by the local complications, 
must be used promptly, and in quick succession, as the 
disease makes much more rapid progress than the con- 
tinued fever of this climate, and the remissions are not 
such as to enable us to use remedies between the pa- 
roxysms, with any advantage. 

Although there is some diff'erence of opinion among 
practitioners, who have seen much of the Remittent 
Fever, as to the efficacy of Mercury, yet it may be stated, 
as the most general opinion, that if it is given in large and 
repeated doses, and if these take efl'ect in the system 



464 OUTLINES OF PATHOLOGY AND PRACTICE. 



(which they very often fail to do), it appears occasionally 
to arrest, or greatly mitigate, the progress of the disease; 
and although we certainly cannot ascribe any such 
power to Mercury in the fevers of this climate, we are 
not, on that account, entitled to set aside that observa- 
tion ; more especially as a very important part of the 
disease, in the worst cases in the hot climates, consists 
in the suppression of the excretions of Bile and Urine, 
which is hardly seen in the fever of this climate ; but 
when occurring in other diseases, appears to have been, 
in a few instances, controlled by the full action of Mer- 
cury. 

When the Remittent Fever subsides, it very often 
leaves behind it an Intermittent Fever, which may last 
much longer, and for a still longer period be easily re- 
produced by cold, especially exposure to the east wind, 
fatigTie or intemperance ; and this consequence clearly 
denotes that the Remittent Fever (at least of most 
seasons) is only the highest grade of the Intermittent. 

The treatment of the Intermittent Fever diflPers essen- 
tially from that of the Continued, in this, that little or 
nothing is in general to be done during the paroxysm, 
the chief remedies being reserved for the intermission. 

The Antiphlogistic regimen, diluents, and diaphore- 
tics, should indeed be directed during the paroxysm : in 
cases of violence, leeching and purging will be useful ; 
the cold affusion has been used in the hot fit with good 
effect, — more generally a full opiate, given in the be- 
ginning of the hot fit, has seemed to shorten the 
paroxysm remarkably ; and the practice of bleeding in 
the cold fit has appeared to have a similar effect : but 
the effect of all these remedies is only to abridge some- 
what a paroxysm which will at any rate be over in a 

5 



OF IDIOPATHIC FEVER. 



465 



few hours; and all of these, and especially the last, 
will leave a certain degree of debilitating effect after- 
w^ards ; and therefore, unless the disease is of unusual 
intensity, they may very often be properly omitted. 

The main object in this disease is, the proper adminis- 
tration of the specific remedy, the Bark or Quinine, 
during the intermission. The only preparation requisite 
in a case not complicated, before beginning to use this, 
is to secure the complete evacuation of the bowels. The 
Quinine is then to be given in repeated doses, the more 
frequently as the previous paroxysm has been more vio- 
lent ; and it has often been found useful to give a double 
or even triple dose immediately before the expected pa- 
roxysm. Sometimes the treatment is baffled by fre- 
quent vomiting, but this may often be controlled by 
purging with Calomel, by saline effervescent mixtures, 
and by the opiate Enema, at least so far as to allow the 
medicine to be taken in pills. In some instances it has 
answered when given in large doses by giyster. 

The success of the remedy is generally promoted by 
a moderate allowance of fermented liquor, and, if the 
appetite permit, of animal food during the intermission. 

Under this treatment the paroxysms usually become 
later and slighter, and then disappear entirely, unless 
the disease is kept up, either by reapplication of the 
cause, or by exposure to cold, or excess of some kind, 
or by the presence of organic disease, perhaps conse- 
quent on former paroxysms. 

The Arsenical Solution taken in like manner, in re- 
peated small doses, during the intermissions, has un- 
doubtedly a similar specific effect, and has sometimes 
been effectual when the Bark or Quinine has failed. 

When the disease is combined with decidedly inflam- 



4b*6 OUTLINES OF PATHOLOGY AND PRACTICE. 



matory action in any organ, tliat state ouglit to be much 
mitigated by the antiphlogistic treatment, before the use 
of the specific remedy is begun. 

The state of the Liver and Spleen, and of the stomach 
and bowels, require much attention after Intermittent 
Fever has declined ; removal from a malarious district is 
the first indication : enlarged Liver, with deficient secre- 
tion of Bile, is often benefited by the cautious use of Mer- 
cury, with other laxatives, the saline mineral waters and 
bitters ; enlarged spleen (almost always injured by the 
use of Mercury) is stated to be best treated by repeated 
blisters, and combinations of laxatives with preparations 
of Iron. The bowels sometimes require laxatives, and 
sometimes astringents, and both should be used with 
caution, so as to restore as soon as possible the natural 
daily evacuation. The diet must be carefuUy regulated, 
as the disease is easily reproduced by any disorder of the 
stomach, whether from the use of food difficult of di- 
gestion, or irregularity in the times of taking food, or 
any excess in strong liquors. In all cases, much gentle 
exercise, occasional change of scene, and as much of 
the Tonic Regimen as the patient's condition will admit, 
are beneficial. 



( 467 ) 



CHAPTER II. 

OF CONTAGIOUS EXANTHEMATA, OR ERUPTIVE FEVERS. 

We here treat of diseases, caused chiefi j if not solely 
by contagion, and therefore prevailing at times epide- 
mically, in which there are symptoms of general fever, 
more or less of the typhoid character, — and at the same 
time an eruption on the skin (as in many cases of the 
continued fever already described) ; in which there is 
very generally likewise inflammation, chiefly of the mu- 
cous membranes, in internal parts ; and the danger ap- 
pears to depend, seldom on the extent of inflammation 
on the surface, but partly on those internal inflamma- 
tions, and partly on the afl*ection of the general system, 
and especially of the circulation, which results from the 
action of the morbific cause. There are these material 
differences from continued fever, that the duration of 
the febrile action is generally shorter, and much more 
uniform, and that the whole succession of the symptoms, 
and especially the course of the external inflammation, 
is much more regular. This description applies chiefly 
to Smallpox, Measles, and Scarlatina, and probably also 
to the Plague. It applies also to the slight disease called 
Varicella ; and in several important particulars, to the 
Erysipelas. 



468 OUTLINES OF PATHOLOGY AND PKACTICE. 



In all the eruptive fevers except this last, it is to be 
observed, as an important part of their Pathology, that 
experience has shewn the danger of arresting the course 
of the specific inflammation on the skin. Whether 
the body contains a morbific poison, which ought to be 
expelled, or not, it certainly labours under the influence 
of a cause which becomes more dangerous if the inflam- 
mations accompanying it are abortive ; and unwonted 
recession of the eruption, if not a cause of injury, is very 
generally to be dreaded as a sign of such enfeebled cir- 
culation as threatens immediate death by Asthenia. 

The Pathology of these diseases, and especially of the 
combination existing in them all, of local inflammation, 
always of a peculiar or specific character, with general 
typhoid fever, is essentially the same as that of the more 
complex form of continued Fever ; but it is important to 
consider shortly how far the statements made as to the 
history of continued fever are applicable to each of these 
exanthematous diseases. 

In the case of smallpox, measles, and plague, we are 
nearly certain, from facts of the description formerly 
noticed (p. 66), not only that these diseases are con- 
tagious, but that they never proceed, at the present day, 
from any other cause than the specific contagion, thrown 
off probably chiefly in the breath of persons themselves 
affected with the diseases, but likewise existing in the 
excretions formed on the surface of their bodies, as ap- 
pears from the communication of the diseases by inocu- 
lation. But it is more doubtful whether the scarlatina 
and varicella (of which a few cases occur almost every 
season in this country, and which less frequently spread 
epidemically to great numbers of persons), do not occa- 
sionally arise from unknown causes, and then spread by 



or CONTAGIOUS EXANTHEMATA. 



469 



contagion ; and of tlie frequent sporadic origin, and only 
occasional communication by contagion, of the erysipe- 
las, there can be no doubt. 

In this last case, it seems nearly a necessary condi- 
tion to the communication of the disease by contagion, 
that an inflammation of the skin, or at least an abrasion 
of the cuticle, whether by wound, bruise, scratch, blister, 
or some other cause, should exist at the time that the 
morbific poison is presented. It has also been supposed 
that some derangement of the digestive organs is an es- 
sential condition to attacks of erysipelas, but it does not 
appear ascertained that such derangement does more 
in this than in various other cases of exposure to the 
causes of acute disease, viz. strongly predispose to their 
development. 

The protection against future returns of the disease 
given by its once taking place, which was mentioned as 
frequently observed in regard to continued fever, is 
nearly absolute in the case of smallpox, measles, scar- 
latina, and probably varicella ; though a few exceptions 
to the rule have been observed in all these cases ; but it 
does not hold so surely of plague, and the reverse ap- 
pears to hold of erysipelas. 

The singular and anomalous facts as to the connexion 
of smallpox and cowpox may be thus stated. That the 
contagious matter of smallpox may be so applied as to 
act on the living system of the horse and the cow,* and 
excite in them a mild vesicular disease, without any 
general eruption, and without constitutional disturbance ; 
and that this local vesicular disease, communicated to 
the human subject by inoculation, runs its course there 
in the same innocent manner ; with the effect of pro- 

* See Edinburgh Medical and Surgical Journal, 1831. 



470 OUTLINES OF PATHOLOGY AND PEACTICE. 



tecting the system, in a great majority of cases, against 
all subsequent influence of tlie contagion of smallpox ; 
and witli tlie effect, in almost all cases, where the pro- 
tection given by it is not absolute, of so modifying the 
disease which that contagion can excite, as to arrest the 
progress both of the cutaneous inflammation and of the 
fever, about the end of the first week, and so render it 
nearly free from danger. 

The contagious poison of all these diseases, like that 
of continued fever, is liable to great variations,— in effi- 
ciency, as seen in the diffusion of epidemics, — in viru- 
lence, as seen in their mortality ; and in specific charac- 
ter, as seen in the most urgent symptoms, and most fre- 
quent accompaniments of the diseases, as occurring in dif- 
ferent seasons. The epidemics of smallpox are perhaps 
chiefly seen in the summer ; those of measles in winter 
of this climate. The diffusion of measles is generally 
the most rapid of any, that of smallpox next, and that 
of scarlatina, in most seasons, the least rapid ; although 
occasionally, and within narrow limits, it appears to be 
propagated with extreme facility. Of the natives of 
large towns, there are few adults who have not passed 
through measles, and one form or other of smallpox, 
and on this account in these the mortality of both these 
diseases falls very much on children below the age of 
ten.* 

* Mr Watt's curious tables give the following results on this 
point. Of the whole mortality from these diseases, there are,— « 

DEATHS UNDER TEN YEARS. 

Measles. Scarlatina. Smallpox. 

Per cent. Per cent. Per cent. 

Edinburgh, , . 92 64 82 

Glasgow, . . 85 70 85 

Perth, ... 92 63 87 

Dundee, . . 90 ^6 85 



OF CONTAGIOUS EXANTHEMATA. 



471 



In all these diseases tlier^ is so distinct an eruptive 
fever, although of various duration, before the inflam- 
matory appearances in the skin commence, as unequivo- 
cally to demonstrate that the inflammation, — although 
an effect, and the only sure criterion, of the specific poison 
which excites tire fever, — is not the cause of the fever ; 
which must therefore be held, like idiopathic fever, to ' 
consist in the reaction of the system against the depres- 
, sing influence of the specific poison. The internal in- 
flammations attending these diseases, although often ag- 
gravated by the usual causes of inflammation, applied at 
the time, ar« yet so uniformly observed, and so frequently 
severe when there has been no such concurrent cause, 
that we must regard them as likewise effects of the spe- 
cific poisons. 



Sect. I. — Of the Smallpox. 

The Smallpox is distinguished by the pretty uniform 
dm-ation, both of the latent period (from seven to twelve 
days), and of the eruptive fever (from thirty-six to sixty 



DEATHS UNDER TWENTY YEARS. 

Measles. Scarlatina. Smallpox. 

Per cent. Per cent. Per cent. 
Edinburgh, . . 99 98 95 
Glasgow, . . 99 9? 95 
Perth, . . .100 98 91 
Dundee, ... 100 95 94 



DEATHS ABOVE TWENTY YEARS. 

Edinburgh, . . -03 1-8 4-7 

Glasgow, . . '06 2-04 4-8 

Perth, ... 0 1-4 8 

Dundee, ... 0 4-6 6-1 



472 



OUTLINES OF PATHOLOGY AND PRACTICE. 



hours) ; by the pustular character of the eruption, — and 
the appearance of the incipient pustules shewing always 
depressions on their tops after the second day ; an erythe- 
ma, or roseolous rash often attends the beginning of the 
eruption, but disappears in two days. The suppuration 
is not completed till the seventh or eighth day from the 
appearance of the inflammation, and, when the eruption 
is numerous, is followed by secondary fever for some days 
more. The pustules usually exist in numbers on the 
eyelids ; but hardly on the conjunctiva of the eyes ; they 
are numerous in the mouth and throat, and are occa- 
sionally seen in the larpix, but hardly suppurate com- 
pletely there, and probably never extend to the sto- 
mach. 

In this disease the peculiar action of the contagious 
poison on the Nervous System is often shewn, in the 
case of children, by convulsions before the eruption 
comes out. The fever is seldom attended with so great 
depression of the circulation, as is seen in the more 
* malignant cases of other epidemic diseases ; the pulse 
is generally full, even at the decline of the eruption, 
and the disease is very generally protracted at least 
until the usual time for the maturation of the pustules ; 
but when their number is very great, the powers of the 
system are inadequate to the filling of the vesicles that 
had formed in the skin, or to the conversion of the fluid 
in them into pus. Hence the peculiarity, and likewise 
the fatality, of the Confluent Smallpox, which is gene- 
rally, in fact, a vesicular disease, where the vesicles con- 
tinue flat and broad to the last ; and which is very gene- 
rally fatal about the eleventh day, even when there is 
very little complication of local inflammation. 

When symptoms of Purpura, or of the Haemorrhagic 



OF CONTAGIOUS EXANTHEMATA. 



473 



diathesis, attend the disease, as happens occasionally in 
all Epidemics, but with peculiar frequency in some (as 
in the Variolce nigrce of Sydenham), it is often fa- 
tal at a considerably earlier period, and although the 
eruption be quite distinct ; and the fatal event is gene- 
rally preceded by coma and convulsion. When un- 
attended with that complication, the distinct Small- 
pox is usually free from danger ; and even what has 
been called the Coherent^ where a part only of the pus- 
tules on the face are confluent, but the whole fill up 
thoroughly, and their contents become quite purulent, 
usually terminates favourably, if the patient is in to- 
lerably favourable circumstances, and there is no pecu- 
liar complication. 

The mucous membrane of the fauces, however, and 
the tunica conjunctiva of the eyes, are very generally 
inflamed early in the disease, and that of the trachea 
and bronchise, in a greater or less degree, in the later 
stages. The substance of the lungs likewise often under- 
goes changes similar to those described as occurring 
there in or after Fever. The mucous membrane of the 
stomach and bowels is more rarely and more variously 
affected. 

The chief danger is of death by Asthenia, or ex- 
haustion, generally attended with much comatose ten- 
dency, and rapidly increasing about the time of the 
maturation, when fresh rigors, preceding, in more fa- 
vourable cases, the attack of secondary fever, are to be 
expected. The Dyspnoea resulting from Laryngitis, 
Bronchitis, and even partial Peripneumony, aggravates 
the danger much in many cases, and makes some fatal 
when there is little confluence of eruption ; but the in^ 
flammation at the larynx hardly ever goes to any other 



474 



OUTLINES OF PATHOLOGY AND PRACTICE. 



termination than thickening of tlie membranes ; and 
tlie condensation of tlie lungs, found after death, is sel- 
dom to a great extent, and often of the kind described 
as ^' Peripneumonie des Agonisans," rather than hepa- 
tization. 

After the disease has nearly or wholly subsided, in- 
flammation, going with peculiar rapidity to suppura- 
tion, is very apt to occur in different parts, most gene- 
rally in some part of the subcutaneous cellular texture, 
— occasionally in the eye, — less frequently in the joints, 
- — more frequently in the pleura, — and in small por- 
tions of the substance of the lungs, — in which it some- 
times goes on likewise to sloughing. And on any ex- 
posure to cold, for long after the disease, scrofulous in- 
flammation, in any one disposed to it, is very easily ex- 
cited. 

The Eruptive Fever of Smallpox is often so intense, 
and attended with so much flushing and headache, as 
to suggest the use of Bloodletting ; but although these 
symptoms are relieved by it, the quantity of the coming 
eruption is not found to be diminished ; and the un- 
certain amount, and necessarily long duration, of the 
diseased action, which is inevitable, of course make all 
large evacuations at that period inexpedient. There 
is statistical evidence, particularly as to the practice of 
the empirical inoculators, which seems sufficient to 
shew, that, by purging, and by the prudent application 
of cold in the eruptive stage, the duration of this may be 
increased, and the quantity of the eruption and danger 
of the disease may be considerably diminished. After 
the eruption has come out, and th^ degree of violence 
of the disease, which is in general measured by the 
quantity of eruption, is determined, the practice to be 



OF CONTAGIOUS EXANTHEMATA. 



475 



employed has the same ohjects, — of paUiation rather 
than cure, — and does not differ from that which we 
would recommend for Continued Fever, with the com- 
plication of local disease here existing, — excepting in 
this, that, as an additional cause of irritation exists in 
the state of the skin, and as the affection of the nervous 
system is seldom urgent, it is important to allay this un- 
easiness by opiates given daily, or sometimes twice a day, 
from about the fifth day of the eruption, unless these are 
clearly contra-indicated by Coma ; and that mild Lini- 
ments applied very frequently to the surface give con- 
siderable relief to that irritation. In the later stages, 
indeed, more stimulating applications, such as a weak 
Solution of Chloride of Lime, to allay itching, or a li- 
niment containing a little of the Oil of Turpentine, 
when there is superficial sloughing, are useful. 

The €arly evacuation of the contents of the pustules 
has been found, by ample experience, to be ineffica- 
cious ; and the cauterization of the pustules to be unsafe ; 
but there are two situations in which the application of 
Caustic, or its Solution, in the early stage, — arresting 
the inflammation and all its effects,— has been found 
distinctly useful, viz. on the eyelids, and in the fauces. 

The modified or mild Smallpox, so frequently seen 
in those who have been vaccinated, is distinguished from 
the natural disease, not by any mitigation either of the 
degree or duration of the eruptive fever, or of the 
quantity of the eruption, or of the appearance of the 
papulae in the commencement ; but in the circumstance 
that the fever and inflammation subside earlier than 
usual, and there being no secondary fever, the dangerous 
part of the disease (excepting in the case of an unusual 
complication) is avoided ; and of course, unless in com- 



476 OUTLINES OF PATHOLOGY AND PRACTICE. 



plicated cases, little or no treatment is demanded. 
Sometimes, in snch cases, the pustules, or a part of 
them, run the usual course, but complete it by the 6 th 
day, instead of the 8th ; but more generally they are 
small, show little of the depression on their tops, and 
either become wholly abortive, or harden into dry scabs, — 
which then appear set on dusky-coloured tubercles, — 
without ever shewing pus in their interior. It is perfectly 
ascertained, that the occurrence of this form of the dis- 
ease cannot be ascribed to improper vaccination ; it be- 
ing very often seen in persons who have the mark of 
perfect vaccination, viz. a depressed and indented cicatrix 
on the skin, a quarter of an inch or more in diameter. 

The most important question in regard to this miti- 
gated form of Smallpox is, whether it is more apt to 
occur, or approaches nearer to the natural disease, in 
those vaccinated long previously to its appearance ; and 
the fairest conclusion that can be drawn from the 
facts hitherto ascertained is, that, if not occurring 
more frequently, it is oftener severe in those long pre- 
viously vaccinated, than in others, — whence it may be 
inferred, that, when the disease is prevalent, revaccina- 
tion may be an effectual preventive as to some who 
might otherwise be affected. 

The variety as to the virulence of the poison of 
Smallpox, in different seasons, appears especially from 
this, that the proportion of the vaccinated who take the 
disease, usually very small, has in some epidemics 
formed a large proportion of the whole exposed to the 
contaoion. 

The Varicella is a vesicular contagious eruption, pre- 
ceded and attended by slight fever, and lasting only 
four or five days, and demanding only the mildest anti- 



or CONTAGIOUS EXANTHEMATA. 

I 



477 



phlogistic treatment, or even the regimen only ; but it is 
important to attend to its diagnostic marks, because 
ungrounded alarm in some cases, and misplaced con- 
fidence in others, may result from its being confound- 
ed with smallpox. It is distinguished especially by 
the vesicles being larger, in proportion to the inflamed 
bases on which they stand, of more oval form, the layer 
of cuticle containing them thinner, and arising much 
more quickly, each attaining its full size in forty-eight 
hours or less, although several coming out in succession 
usually prolong the disease a few days more. The in- 
flamed base is also less elevated ; and the fluid efliised, 
imless from mechanical irritation, never becomes puru- 
lent ; the cutaneous inflammation being, in fact, more 
superficial. By these marks, and by the eruptive fever 
being shorter and slighter, this disease may be distin- 
guished from the modified as well as the regular small- 
pox j and the truth of the distinction becomes obvious 
when it attacks a family of which some have been pre- 
viously vaccinated and others not, and is found to shew 
the same characters in all. 



Sect. II. — Of the Measles, 

In this disease, the duration both of the latent period, 
and of the eruptive fever, is less uniform than in the 
Smallpox, — sometimes protracted for six or eight days. 
The disease is distinguished by the peculiar form (ge- 
nerally approaching to the crescentic), and the brownish 
red colour of the patches of eruption on the skin, which 
begins on the face, soon becomes general, and lasts 
about four days in the regular form, — the patches gra- 

3 



478 OUTLINES OF PxiTHOLOGY AND PRACTICE. 



dually enlarging, and becoming of a deeper colour, — and 
fades away without any other effect than partial separa- 
tion of the cuticle in minute powdery scales ; and also 
by the inflammation of the tunica conjunctiva of the 
eyes, and of the nasal mucous membrane, during the 
eruptive fever, and of the membrane of the larynx, 
trachea, and bronchia?, causing a peculiar hoarse cough, 
and more or less of dyspnoea, during the continuance of 
the eruption ; which in severe cases go on, and even in- 
crease, after the eruption has faded ; — in general also 
by diarrhoea, sometimes taking the form of dysentery, in 
the decline of the eruption. 

In ordinary cases, and in most epidemics, the fever 
is of considerably shorter duration than that of Small- 
pox, and shews no typhoid symptoms, but is liable to 
protraction when the inflammation of the mucous mem- 
branes is more violent and lasting than usual. But in 
certain cases, probably in all epidemics, and in many 
cases in certain seasons, the fever has quite what was 
described as the adynamic, or even the congestive 
form ; {. e. the depression on its first attack is extreme, 
and the reaction feeble and imperfect : in such cases 
the tongue is often dry, and there is always much nau- 
sea and vomiting, and tendency to coma, — sometimes 
diarrhoea, — and the inflammation on the skin appears 
late, and is pale or livid, partial, and of short duration, 
often lasting only a few hours in one part. 

On dissection after fatal measles, — unless unusually 
complicated, — the only morbid appearances are those of 
Bronchitis ; i. e. much muco-purulent effusion, often very 
general in the bronchiee, with congestion and serous 
effusion in the lungs. If either Pleurisy or decided 
Peripneumony exist, it is to be regarded as an unusual, 



OF CONTAGIOUS EXANTHEMATA. 



479 



perhaps often as an accidental complication. In the 
abdomen, ulceration of the mucous membrane is found 
only in cases that are unusually protracted by diarrhoea, 
and in which the death must be ascribed to the local af- 
fection only. 

The danger of the disease, in most epidemics, is only 
from an unusual intensity of the accompanying bron- 
chitis, indicated by the appearances above mentioned, and 
is greatest about the time of the decline of the eruption. 
But this bronchitis is probably always the more dan- 
gerous, as it occurs in a system which is under the in- 
fluence of a weakening disease, independent of itself; 
and the malignant typhoid fever above described as oc- 
casionally attending measles, is very dangerous, even 
independently of any complication with bronchitis ; and 
when that complication exists in a certain degree, is in- 
evitably fatal. 

In weakly, especially scrofulous, constitutions, the 
bronchitis of measles not only lasts after the eruption 
has declined, but becomes chronic,— sometimes com- 
plicated with Asthma, and often passes gradually into 
Phthisis ; and in like manner the inflammation of the 
eyes and eyelids becomes chronic, and passes into the 
forms of Strumous Ophthalmia, formerly described. 

A great majority of cases of Measles, in most epi- 
demics, terminate favourably in a few days, without any 
treatment but the antiphlogistic regimen. Even where 
there is considerable oppression and laboured breathing, 
during the eruption, we know that this depends on in- 
flammation of the mucous membrane contemporaneous 
with that of the skin, and which may subside com- 
pletely at the tim.e of the fading, without any active 
treatment ; and we may therefore wait until the de- 



480 OUTLINES OF PATHOLOGY AND PRACTICE. 



cline of the eruption, and apply remedies then if the 
pectoral affection shall continue or increase. But if 
the cough, pain on coughing, and dyspnoea, are dis- 
tinctly observed to be greater than usual, general or 
local bleeding, purging, and Antimonial Solution or 
Ipecacuan, followed by blisters (to be applied only for 
a short time), and the cautious use of opiates, are to be 
prescribed, even during the eruption, as in the compli- 
cation of continued fever with bronchitis, and in general 
with less scruple than in fever, because we know that the 
general fever attending the local inflammation is to be 
sooner over. And if the fever, attending the bronchitis, 
be of the typhoid form, it will be too late to use any form 
of bloodletting after the eruption has declined. 

In some cases, even of this last kind, local blood- 
letting to a small extent, with the other means above 
mentioned, may be useful ; but blisters, in cases of the 
typhoid character in children, should be avoided ; and 
the cautious use of wine and other stimuli, as in the 
similar complication of continued fever, is certainly use- 
ful. Indeed, in cases of this malignant form of measles, 
when the bronchitis is slight, but the depression great, 
with lividity, coldness, and nausea, the good effects of 
Stimulants are sometimes unequivocal and striking. 

The Bronchitis succeeding measles always requires 
careful attention, and caution as to exposure to cold, 
until the strength is fairly restored, on account of the 
known tendency to chronic inflammation, and to scro* 
fulous disease at that time, and the frequent occurrence 
of tubercular Phthisis, as a consequence of the disease. 



OF CONTAGIOUS EXANTHEMATA. 481 



Sect. III. — Of the Scarlatina and Malignant Sore- 

Throat. 

This is a contagious febrile disease, characterized by 
an Exanthema, or Scarlet rash, generally of more florid 
colour, and always more uniform and continuous, than 
that of measles, — and, at the same time, an inflamma- 
tion of the mucous membrane of the nose, fauces, and 
tonsils, and of the lymphatic glands beneath the angle 
of the jaw, — which inflammation in the tonsils very 
often goes on to ulceration, and sometimes to slough- 

There is very great variety in the history of the dif- 
ferent cases, to which this general description applies ; 
both in difl"erent epidemics, and in diflerent cases of 
the same, — as to the rapidity of extension, — the in- 
tensity of different parts of the symptoms, — the com- 
plications, sequelae, and mortality of the disease. These 
varieties led the older pathologists to suppose that there 
are really two diseases, — the Scarlatina, in which the 
eruption in the skin is the most prominent part of the 
disease, and the inflammation of the throat leads to no 
bad ulceration ; and the Cynanche Maligna, in which 
the eruption is usually less florid, the fever more ty- 
phoid, and the afl"ection of the throat goes to rapid ul- 
ceration or sloughing. And since it has been generally 
admitted, that all forms of the disease spring from the 
same contagion, three varieties have been usually de- 
scribed, — the Scarlatina Simplex, in which there is sore 
throat only, without ulceration, — the Scarlatina Angi- 
nosa, where there is ulceration and much swelling of the 

Hh 
I 



482 



OUTLINES OF PATHOLOGY AND PRACTICE. 



fauces, without rapid depression of the vis vitse, — and 
the Scarlatina Mahgna, where the general symptoms are 
very much those described as the congestive form of 
Fever, and there is generally rapid sloughing of the 
tonsils. But the varieties observed are more numerous 
than can be comprehended under these distinctions. 

Th€ whole progress of the disease is short ; it has 
been fatal occasionally within 24 hours, and most of the 
fatal cases, referable to the disease itself, take place 
from the Bd to the 7th day. 

The appearance of the tongue is generally very cha- 
racteristic ; at first it has a thick white fur, through 
which the red and enlarged papillae protrude, and gra- 
dually the fur clears off, and the surface remains of an 
unusually florid colour. 

The Eruptive fever is of very various intensity and 
duration, generally attended with vomiting ; frequently 
the rash appears during the first day, but it is often 
delayed till the third or fourth. Frequently it is in 
large uniform and continuous patches from the first ; 
but sometimes it begins in numerous small points, re- 
sembling measles, which afterwards extend and coalesce: 
in some cases the eruption is very partial, but of the 
usual florid colour ; in others, partial and faint or livid: 
in most cases it remains distinct three or four days, but 
in some it fades within a few hours ; and there are a 
considerable number of cases of persons exposed to the 
contagion, who are affected with sore-throat, sometimes 
with ulceration of the throat, enlargements of the lym- 
phatic glands, and fever^ without any eruption. 

Most frequently, the cases of early, general, florid, 
and persistent eruption admit of a favourable prognosis, 
being usually attended with a firm pulse, and a state of 



OF CONTAGIOUS EXANTHEMATA. 



483 



the system which bears evacuations well ; but there is 
a considerable number of cases where the eruption is 
florid and persistent, but the pulse soon becomes feeble 
and the fever typhoid, and the strength sinks rapidly 
under evacuations, particularly of blood. 

On the other hand, an eruption which appears late, 
or, even if early, which is somewhat livid, partial, and 
quickly fading, is usually attended Avith great depression 
of strength, much retching and vomiting, the comatose 
tendency, and rapid sinking ; yet there are some cases, 
at least of the very partial eruption, where all the other 
symptoms are mild. 

In a few cases the full, florid, and persistent eruption, 
is attended with delirium, coma, and death in the way 
of coma, the pulse continuing full to the last ; but in 
most cases of this description, although there is intense 
heat of skin, and often delirium, the reaction soon abates, 
and, if the disease go on unfavourably, it is attended, in 
the later stage, with soft or feeble pulse. 

The local afl'ections in the fauces and nostrils, — the 
ulceration of the tonsils, painful swelling of the glands 
beneath the angle of the jaw, and often of the cellular 
membrane there, and ichorous discharge from the nos- 
trils, — may coexist with different states of the constitu- 
tional fever, but are always most dangerous when going 
along with the bad typhoid symptoms, — soft or feeble 
pulse, dry tongue, typhoid delirium, and comatose ten- 
dency. The increase of these, and particularly of the 
submaxillary swellings, at the height, or even during 
the decline, of the eruption, chiefly observed in young 
children, is apparently the immediate cause of such ag- 
gravation of the febrile state, as is the immediate cause 
of death in many cases. In such cases the death is 



484 OUTLINES OF PATHOLOGY AND PRACTICE. 



sometimes evidently by Asphyxia, from straitening of 
the glottis ; sometimes caused by a distinctly inflamma- 
tory exudation within the larynx. 

When the fever is of the most malignant or conges- 
tive kind, attended with extreme oppression and weak- 
ness, it may be fatal before there is time for any of 
these local affections to advance to any length ; and in 
all cases the danger from them is greatly aggravated by 
the typhoid form of fever usually attending them. 

Before the proper symptoms of the Scarlet Fever 
have abated, various effects may result from the affec- 
tion of the fauces, by which the danger of the disease 
may be much aggravated ; the inflammation may ex- 
tend down the larynx, lead to the effusion of a floccu- 
lent false membrane, and cause the symptoms of croup ; 
it may extend up one or both the Eustachian tubes, 
cause destruction of the membrane of the tympanum, 
escape of the small bones, and incurable deafness, with 
palsy of the facial nerve ; or it may extend downwards 
along the cellular membrane of the neck and arms, with 
aggravation of the typhoid fever : And if the enlarged 
glands at the angle of the jaw suppurate, or if they be 
leeched or blistered, in the typhoid or malignant cases, 
rapidly spreading and phagedsenic ulceration may ensue. 

More frequently, after the whole symptoms of the 
Scarlatina have abated, and the desquamation of the 
cuticle (usually in pretty large patches on the extremi- 
ties) has begun, or been completed, various sequelae fol- 
low, by which the life of the patient is again endanger- 
ed. These are all of a character more or less distinctly 
inflammatory, and are attended by more or less of re- 
newal of the febrile symptoms. Sometimes the swel- 



OF CONTAGIOUS EXANTHEMATA. 485 



lings beneath the maxillae, especially in young children, 
enlarge rapidly at this time, and cause renewal of the 
fever, either of a simply inflammatory or a more typhoid 
type ; sometimes there are rapidly increasing swellings 
of the joints, or of parts in their neighbourhood, tend- 
ing quickly to purulent deposits ; sometimes there are 
symptoms of inflammation, and rapid eff'usion in the 
head, sharp pain, sickness and vomiting, blindness or 
imperfect vision, coma and spasms ; sometimes inflam- 
mation, tending also rapidly to effusion in the lungs, 
pleura, or peritoneum ; and, frequently in connection 
with these internal inflammations, — but frequently also 
without such complication, — we have Anasarca, or even 
more general dropsy, with scanty and albuminous urine, 
known to depend on granular degeneration of the kid- 
neys. There are many instances also of patients 
escaping all these dangers, who fall into Phthisis, or 
other scrofulous disease, as a consequence of Scarlatina. 

For these sequelae of the disease, some external 
cause, especially exposure to cold, may most generally 
be assigned ; but in some instances they supervene with- 
out obvious cause ; the affection of the kidneys, certainly 
much more frequent after this than other Exanthema- 
tous diseases, has been thought to be partly dependent 
on the morbid state of the skin during the eruption and 
desquamation, but has certainly sometimes been ob- 
served to follow the disease, when it consisted only in 
ulcerated sore-throat and typhoid fever, proceeding 
from the contagion of Scarlatina, but without the erup- 
tion. 

The Prognosis in this disease is, therefore, always ex- 
tremely uncertain ; it is unfavourable when the fever 



486 OUTLINES OF PATHOLOGY AND PRACTICE. 



has the bad typhoid or congestive form, and when the 
ulceration of the throat, and the different local affec- 
tions in connection with that ulceration, are well mark- 
ed. The disease itself is fatal to many, especially young 
children, and remarkably more fatal in some families 
than others ; but after the original disease has subsided, 
the various sequelae that have been mentioned, are al- 
ways attended with danger, and this the more, as the 
symptoms are more obscure and insidious ; the most 
acute and best marked cases of these inflammatory 
affections being generally the most manageable in prac- 
tice. 

The great variety in the natural course of the dis- 
ease, both in individual cases and in different epide- 
mics, makes it obviously absurd to lay down any uni- 
form plan of treatment for the disease, and extremely 
difficult to judge of the real efficacy of any one method. 

There are undoubtedly cases, and even epidemics, 
in which the whole course of the symptoms, general and 
local, has approached very near to that of healthy in- 
flammation and concomitant fever : repeated bloodlet- 
ting, as well as purging, have been well borne, the most 
urgent symptoms been manifestly relieved by these re- 
medies, and the mortality under this practice been very 
small but experience has equally shewn, that the ex- 
pectation entertained by Dr Armstrong and others, that, 
by early depletion, the congestive or malignant form of 
the disease may be made to assume the more healthy 
form of inflammation and fever, is hardly ever rea- 
lized ; and in many cases, although the pulse has been 
full, and the eruption florid in the beginning, bloodlet- 

* See e. g, Dr Dewar of Dunfermline, in Edinburgh Medical 
and Surgical Journal, 1835. 



OF CONTAGIOUS EXANTHEMATA. 48T 



ting (even local bloodletting) has been followed by a 
rapid change of the fever to the typhoid type, and 
manifestly aggravated the danger. It is therefore only 
when repeated observation of the usual course of an epi- 
demic, and cautious trial of the remedy, have shewn 
that this change of the febrile symptoms is not to be ap- 
prehended, that we are safe in adopting this practice. 

The other remedies by which the intensity of the fe- 
brile reaction, in the early part of the disease, may be 
more safely and often beneficially moderated, are the ap- 
plication of cold, and purging, which have been carried to 
a great length by many, since the works of Currie and of 
Hamilton were published, and may often be properly 
combined ; but these must be reg-arded as chiefly useful 
in that description of cases in which the febrile reaction 
is strongest and jnost enduring, but in which the danger 
and mortality of the disease are least. 

No observations have distinctly proved whether any, 
or which, of these antiphlogistic remedies, used early in 
the disease, can be relied on as preventing either the ty- 
phoid tendency of the fever, or the bad ulceration, sub- 
maxillary swellings, or other local consequences, to 
be dreaded in the advanced stage, or any of the sequelae 
above mentioned, which are to be subsequently appre- 
hended ; and although it seems reasonable to conjec- 
ture, that whatever moderates the febrile reaction early 
in the disease, will tend to avert these consequences, 
yet as we frequently see them all, in cases where that 
reaction had been very moderate, or even morbidly de- 
ficient, we m.ust, at present, regard the effects of all 
these remedies on the ulterior course of the disease as^ 
doubtful. 

In the most malignant cases, from the beginning, an4 



488 OUTLINES OF PATHOLOGY AND PRACTICE. 

in cases which gradually take the typhoid form, as soon 
as that tendency has clearly shewn itself, stimulants, 
especially wine, must be given, as in idiopathic fever ; 
and the pulse is often observed to improve under their 
use, and recoveries to take place, where the circulation 
had previously been so much depressed, that without 
their aid death, by Asthenia, appeared inevitable. 

The effects of stimuli on the local symptoms, as well as 
the pulse, should, however, be carefully watched ; and in 
some cases, when the state of the throat, or the frequent 
vomiting, have prevented their being adequately supplied 
by the mouth, repeated stimulating Enemata, with opium, 
have seemed decidedly useful. 

The act of gargling is so painful, in the severe cases 
of the disease, as to be more injurious than the appli- 
cation of any stimulating or astringent matters in that 
way can be useful ; but the frequent use of drinks, aci- 
dulated with the Mineral Acids, or with the Chlorine 
. water, and sometimes even such stimulating medicines 
as the infusion of Capsicum, have seemed useful to the 
ulcers on the fauces ; and a more effectual means of ar- 
resting their extension, is the application of a solution 
of Lunar Caustic, or Corrosive Sublimate, by a hair 
pencil, or bit of sponge. Such applications, however, 
cannot be expected to have the same decided effects in 
this case, as in ulcers unattended with typhoid fever. 

The submaxillary swellings are not, in general, ar- 
rested by leeches, in such number as the general symp- 
toms will justify, and the leech-bites are very apt to 
form sloughing ulcers. Weak solutions of Acetate of 
Lead, applied tepid, sometimes appear useful ; but in 
other instances, they seem to excite erythematic inflam- 
mation. Warm poultices are the most generally sooth- 



OF CONTAGIOUS EXANTHEMATA. 



489 



ing application ; and when suppuration advances rapid- 
ly, the prospect is favourable. 

As long as the affection of the fauces is formidable, 
the frequent use of laxatives must be regarded as essen- 
tially important. 

It seems, quite certain, that all the sequelae of Scar- 
latina, — including the disease of the kidneys, — may 
often be prevented by warm clothing, and keeping the 
patients within doors, until their strength is nearly re- 
stored. But these sequelae should always be held in 
view, and opposed, as early as possible after they shew 
themselves, by the antiphlogistic remedies suited to ' 
them, and especially by bloodletting, general or local ; 
although, in the subsequent progress of these affections, 
occurring in so enfeebled a state of the body, stimulants 
are again often indicated, and manifestly useful. 

The Anasarca after Scarlatina, when attended with 
febrile and inflammatory symptoms, often abates re- 
markably well after bloodletting, which sometimes must 
be employed repeatedly ; when not attended with such 
symptoms, it is often removed by the use of Digitalis, 
Cream of Tartar, and the warm bath, and diaphoretic 
regimen and medicines ; in both cases, the albumen 
may be observed gradually to disappear from the urine ; 
— sometimes its disappearance has seemed to be acce- 
lerated by the use of Bitters, or other tonics, and of the 
Hydriodate of Potass ; and no doubt this and all the other 
injurious effects of the Scarlatina may often be averted 
by the cautious and gradual application of the tonic re- 
gimen. 



490 OUTLINES OF PATHOLOGY AND PRACTICE. 



Sect. IV. — Of the Erysipelas. 

Referring here to what was stated at p. 178 of the^ 
peculiarities of erythematic inflammation of the skin ; 
and, again, to what was stated at p. 180, 320, and 378, 
of inflammation possessing these peculiarities, occurring 
in the subcutaneous cellular membrane, and in the in- 
ternal serous membranes, at least of the abdomen,- — we 
have only here to state what has been observed of this 
kind of inflammation of the skin, when it takes the 
form of an eruptive fever, — preceded by febrile symp- 
toms, of one, two, or three days' continuance, attended 
by febrile symptoms of very various type, often typhoid, 
and prevailing, if not epidemically, at least much more 
frequently, in some seasons and situations than in others; 
and even undoubtedly spreading, in certain circumstances, 
by contagion. 

The external circumstances, to which the occurrence 
of Erysipelas in certain seasons is chiefly to be as- 
cribed, have not been ascertained ; but the frequency of 
its excitement by mechanical injury, or irritation of the 
skin, and its introduction, in a few instances,, really by 
inoculation, already noticed (p. 179), should always be 
kept in mind. In many other instances, however, it 
originates spontaneously. 

The inflammation, in such cases of Erysipelas, usually 
begins on the head, — frequently on the forehead, or 
about the ears and has sometimes been observed to 
commence there, even when there was reason to think 
that its exciting cause was an injury of some other part 
of the body. In other instances, it appears to be dis- 
tinctly excited by cold. 



OF CONTAGIOUS EXANTHEMATA. 491 



Beginning at one spot in the head, the ery thematic 
inflammation gradually extends in a few days, gene- 
rally bounded by a well-defined line, over the whole 
head, causing closure of the eyelids ; and from thence, 
in the course of a few days more, it often spreads down 
the trunk of the body, — sometimes to the extremities, 
— and in a few cases, more protracted than usual, it 
even goes this course more than once. In some in- 
stances, erythematic inflammation begins, under similar 
circumstances, in other parts of the body, and gradually 
extends to the head. 

This Erysipelas is often attended with inflammation, 
of the same diffused character, in the fauces and larynx ; 
and in a few cases, the inflammation is observed to 
pass inwards from the face by the mouth or nostrils 
(sometimes affecting the tongue as it passes), to the 
fauces. Still more rarely, the opposite course of the 
inflammation has been distinctly observed. The occa- 
sional connection of this disease, when prevailing more 
frequently than usual, with puerperal fever, or with 
peritonitis, shewing a similar tendency of the effusions 
to which it leads, has been already remarked ; and it 
is certain that, in some instances, the external and in- 
ternal inflammation have occurred simultaneously in the 
same person. The same has been noticed in the Erysi- 
pelas which has been repeatedly observed to be epi- 
demic in new-born infants. 

The Erysipelatous inflammation frequently leads to 
vesication on the face as on other parts, — occasionally 
extending inwards to suppura;tion in the cellular mem- 
brane of the eyelids,- — more rarely in other parts of the 
head ; — on the extremities it goes much more frequently 
to suppuration of the diffuse character, and attended with 



492 OUTLINES OF PATHOLOGY AND PRACTICE. 



some sloughing of the celkilar membrane ; in some cases 
there it leads to gangrene. 

The fever attending it is frequently distinctly inflam- 
matory, with much pain of head, and delirium, suc- 
ceeded by coma; while the pulse continues full and 
firm, and the tongue moist ; but in other cases, the fever 
assumes, sooner or later, the typhoid type, with soft or 
compressible pulse, dry tongue, and such muttering de- 
lirium, passing into coma, as we see in simple Typhus ; 
and in the most mahgnant cases of this description, the 
inflammation on the skin is partial, or spreads slowly, 
— has a somewhat livid colour, — and the swelling at- 
tending it is slight. 

In a few instances, the accession of delirium and co- 
matose tendency is attended by sudden recession of the 
cutaneous inflammation, or takes place in the way of 
Metastasis. This is sometimes spontaneous, but in 
other cases has appeared to result from incautious appli- 
cation of cold. 

From what has been stated, it will be readily per- 
ceived, that the danger of the disease (which is always 
to be regarded as a serious one),— the modes of its fatal 
termination, — and the practice by which that termina- 
tion can be avoided, — must be remarkably various. 

In some cases the danger appears to consist chiefly 
in the violence of the attending fever and affection of 
the brain; the death is preceded by coma, with full 
pulse and florid eruption on the skin, almost to the last ; 
and either decided marks of inflammation (in the case 
of Metastasis), or at least serous effusion, to a consider- 
able extent, have been found within the head. 

In other cases, the inflammation, particularly on the 
trunk or extremities, becomes intense, and goes to ex- 



OF CONTAGIOUS EXANTHEMATA. 



493 



tensive suppuration ; and especially if it extend beneath 
the fascise, and to the intermuscular cellular substance, 
the constitutional fever attending it — taking more or 
less the form of Hectic — often gradually exhausts the 
patient. The remedies by which either of these termi- 
nations may be avoided, are evidently the different 
means of depletion, which in many such cases have been 
carried to a great extent with good effect. When the 
intensity of the fever, and accompanying affection of the 
head, seem to constitute the danger, bleeding at the 
arm, with purgatives and antimonials, are our chief re- 
source. When the effects of the local inflammation are 
more dreaded, the local bleedings are of more import- 
ance, and punctures or incisions are generally preferred 
to leeches. Both modes of local depletion appear 
sometimes to arrest the inflammation very speedily ; but 
in other cases, it is either little altered or speedily re- 
newed, even when both methods have been fully tried. 

In cases where extensive suppuration is inevitable, 
and the constitutional symptoms formidable, the inci- 
sions, taking off the tension, and giving vent to the 
effusions and the sloughs, are certainly the most effect- 
ive remedy ; but there are many well-marked cases, 
attended with considerable fever, which do not tend to 
suppuration, or terminate with slight and limited sup- 
puration only ; where the treatment by the antiphlogis- 
tic regimen only, with moderate purging and antimonial 
solution, and no other external application than flour, 
or raw cotton, or weak solution of Acetate of lead ap- 
plied tepid, with careful exclusion of the air, and fo- 
menting and poulticing if suppuration can be felt, — is 
followed by perfectly satisfactory results. 

And it is always to be remembered, not only that in 



494 OUTLINES OF PATHOLOGY AND PRACTICE. 



the advanced stage of the inflammation and suppuration, 
the patient's strength must be husbanded, but that the 
constitutional form of this disease is not by anv means 
dependent on, or proportioned to, the local inflamma- 
tion ; and that it may assume the worst typhoid form, 
and be fatal, when the local inflammation is trifling. 
Such a termination can only be arrested by the reme- 
dies for typhoid fever ; i. e. thorough evacuation of the 
prima? viae at first, and afterwards the saline medicines, 
and more especially the stimulants. The more inflam- 
matory forms of the disease have been chiefly observed 
in the inhabitants of country districts, or small towns, 
and the more typhoid in the inhabitants of large towns ; 
but most towns present numerous examples of both 
forms. 

When recession of the external inflammation and 
affection of internal parts is observed, the treatment 
must depend, as in other cases of the kind, on the na-. 
ture of the internal disease that supervenes. In some 
cases, where it appears to be inflammatory, the anti- 
phlogistic treatment for it is followed by a return of 
the cutaneous inflammation. 

In some instances the Erysipelatous inflammation, 
especially on the extremities, leads to copious eflusion, 
not of pus, but of nearly solid lymph, by which the 
limbs are sometimes flexed, and often greatly swelled 
for a long time. These enlargements are sometimes 
gradually removed by absorption, if rest is enjoined, 
and gently stimulating applications, such as evaporating 
lotions, are employed ; but in other cases, they remain 
for life, and are even repeatedly increased by fresh at- 
tacks of similar inflammation. 



OF CONTAGIOUS EXANTHEMATA. 



495 



Sect. V. — Of the Plague, 

It is only intended here to notice those facts in the 
history of the Plague, which shew that it belongs to 
the great class of Eruptive Fevers, and those which 
indicate its chief individual peculiarities. 

That it is not only a contagious disease, but one 
which has not yet been ascertained to proceed from any 
other source than the specific contagion, appears not 
only from individual facts, shewing that persons who 
have close intercourse with the sick are affected in a 
proportion immensely greater than those who avoid 
such intercourse ; but from facts on a large scale, 
proving the efficacy of different means of seclusion and 
separation, in preventing the extension of the disease, 
even at times and in places where its extension among 
those holding intercourse with the sick, was general and 
rapid, as in the British army in Egypt in 1801; at 
Malta in 1813 ; Corfu in 1815 ; Noya, in Calabria, in 
1816. 

There appear to be at all times isolated cases of the 
disease occiu'ring in the worst parts of the Egyptian and 
Syrian towns, whether from endemic causes, or from 
the contagion still lurking there, in nearly a latent form, 
may be doubted ; from which origin the occasional epi- 
demics proceed. 

It is no objection to the belief in the contagious pro- 
perty of the disease, to observe, that many who have 
intercourse with the sick escape, because the same is 
true of Smallpox, and all other contagious diseases; 
and, in fact, the escape of individuals in places where 
others are affected, is equally an objection to the theory 



496 OUTLINES OF PATHOLOGY AND PEACTICE. 



of the endemic origin, as of tlie contagious property, of 
this or any other disease. 

The observation, which has been often made, when 
this or any other epidemic disease has apparently been 
imported into a town or district, — that some of the first 
cases occur at a considerable distance from the point 
where the importation was ascertained to have taken 
place, and without evidence of intercourse with the 
sick, or their goods, — ^is more important ; and must be 
allowed to shew one of two things, — either that the dis- 
ease may originate, or extend, otherwise than by conta- 
gion ; or else, that the contagious poison may be carried 
about, and perhaps concentrated, on certain spots, in a 
way that we do not understand. But such facts prove 
nothing against the contagious property of the disease, 
if that be established by a fair comparative view of the 
number of seizures in those who have, and in those who 
have not, intercourse with the sick. 

But that the morbific poison undergoes occasional 
variations in intensity, even in a greater degree than 
most others, appears distinctly from the frequent and 
-almost complete disappearance of the disease, in those 
Mahomedan countries where no precautions are taken 
against its extension ; and from the observed effect (in 
most epidemics) both of very hot and cold weather, in 
checking its diffusion. 

The communication of the disease, by means of fomi- 
tes, may be considered as more doubtful than many 
have regarded it ; and the distinctions which have been 
made of substances by which it may or may not be 
communicated, do not appear to rest on any good ground; 
but it would be rash to infer, from the frequent immu- 
mty of persons, as at the quarantine stations, handling 



OF CONTAGIOUS EXANTHEMATA. 



497 



goods supposed to be infected, that no such property 
as tlie communication by fomites exists. 

The most general symptom_s of tlie disease, in its 
worst form, are tliose of the most malioiiant or cono-es- 
tlve form of Fever formerly mentioned, i. e. the symp- 
toms of the first staoe of fever, in their hiohest in- 
tensity, and usually commencing very suddenly, weak- 
ness of pulse, coldness, comatose tendency, vertigo, ex- 
treme feebleness, or irregular action of the voluntary mus- 
cles, nausea and vomiting, sometimes fatal within twenty- 
four hours, and without any local affection, — oftener 
followed by an irregular and often imperfect reaction, 
and with which are combined swellings of lymphatic 
glands (buboes), and gangrenous inflammation of portions 
of the integuments (carbuncles), — ^frequently also pe- 
techiee, passive hsemorrhages, or bloody diarrhoea, indi- 
cating a diseased state of the blood. 

In cases of less malignity, the febrile reaction is bet- 
ter established, assumes a somewhat remittent form, and 
goes on, along with the buboes in the lymphatic glands, 
the carbuncles, and what have been called spurious 
buboes, or swelled and inflamed, and often ultimately 
suppurating portions of the sub-cutaneous cellular tex- 
ture, for many days ; and many such cases terminate fa- 
vourably, — as to the febrile symptoms, by critical sweat- 
ings, and as to the local inflammations, by suppuration, 
with or without sloughing, — while others are fatal, nearly 
in the same manner as in Typhoid Fever. And there 
is a still milder set of cases, in which the buboes and 
other local symptoms shew themselves, and run their 
usual course, almost without any constitutional aftec- 
tion. 

The most malignant cases are usually most frequent 

I i 



498 



OUTLINES OF PATHOLOGY AND PRACTICE. 



ill the beginning of an Epidemic, and the mildest de- 
scription of cases, now mentioned, occur chiefly at its 
close. The whole period of an Epidemic in any town 
or district, is generally from three to four months ; and 
it is generally observed, that the course of Epidemics 
through different towns, is from the south to the north. 

The mortality of the Epidemics is exceedingly various, 
but has often been observed, in pretty large communi- 
ties, to be above 50 per cent, of those affected, or even 
of the whole inhabitants. 

The appearances on dissection have been carefully 
studied of late years, but do not appear to differ from 
those seen after typhoid fever, except that the disten- 
sion of the great veins, and right side of the heart, are 
described as greater ; and that the buboes and car- 
buncles are found in various stages of inflammation. 

The occurrence of these specific local inflammations 
must always be regarded as an essential part of the 
pathology of the disease, and undoubtedly assimilate it 
much more to the specific result of an animal poison 
(such as that of the Smallpox, or that of the Glanders), 
than to the diseases which originate from a Malaria, and 
are properly called Endemic. 

As no means are known which exert any specific 
power over the disease, the only remedies which we can 
recommend are those which we believe to alleviate the 
same symptoms, or moderate the same kind of dis- 
eased actions, general or local, when occurring in con- 
tinued fever, or other febrile diseases. The favourable 
crisis seems to be generally by sweating ; but how far 
this can be effectually promoted by medicine, we are not 
well informed. Mercury taken, so as rapidly to affect 
the system, has been thought by several to have a good 



OF CONTAGIOUS EXANTHEMATA. 



499 



effect on the characteristic symptoms ; but it is doubt- 
ful whether mercury can take effect on the system in 
any cases but those which are tending to the favourable 
termination. 

The most effectual means of preventing the disease in 
individuals seem to be those general tonic measures, 
which fortify the constitution best against other acute, 
and especially febrile diseases. ' The very frequent im- 
munity of persons Avho are habitually besmeared with 
oil, and likewise of persons who have issues or ulcers 
giving a free discharge from any part of their bodies, 
seem to be ascertained and important facts. 

The risk of imbibing the contagion by efHuvia direct- 
ly arising from the bodies of the sick, seems to be very 
much diminished by a very limited distance, — not more 
than a few feet from those persons ; but we can hardly 
doubt that there must be some means by which the 
poison may diffuse itself, at least so as to affect those 
who are predisposed to suffer from its action, at a much 
greater distance. And although the details of Quaran- 
tine Regulations probably admit of much simplification 
and improvement, the evidence of the contagious nature 
of the disease, and the knowledge of its having prevailed 
epidemically in all parts of Europe, are sufficient to 
shcAv the extreme imprudence of any attempt to dispense 
with such regulations. 



END OF PART II. 



PRIXTED BY XEILL & COMPANY, EDINBURGH. 



OUTLINES 

PRACTICE 



OF PATHOLOGY 

AND 

OF MEDICINE, 



PART IIL 

OF CHRONIC OE NON-FEBRILE DISEASES. 



CHAPTEH I. 

OF CHRONIC (OR NON-FEBRILE) DISEASES IN GENERAL. 

The term Non-Febrile is more generally and cor- 
rectly applicable to the diseases which remain for con- 
sideration, than Chronic ; but the usual phraseology 
need not be altered. 

The distinction of Functional and Organic diseases, 
of this class, is of great practical importance, and in 
general easily perceived, if the whole history of a case 
is followed out ; but they are often blended, or gradu- 
ate into one another, and the progress of science tends 
rather to assimilate than separate them. Thus the pro- 
cesses of nutrition and of secretion, and even of nervous 
action, appear, on minute examination, to be more ana- 
logous than was formerly supposed. Again, all Organic 
diseases are the results of morbid change of the function 
of nutrition, and therefore originally functional, in like 
PART. III. K k 



502 OUTLINES OF PATHOLOGY AND PKACTICE. 

manner as inflammation is ; and conversely, many dis- 
eases, commonly called Functional, probably imply al- 
terations of the minute structure, either of the constitu- 
ents of the blood, or of the nervous matter. 

Instead of making a formal division of Functional and 
Organic diseases, therefore, we first study the chief 
changes of both kinds observed in the living body, and 
then arrange the best marked chronic diseases of both 
kinds, simply according to the organs, or sets of organs, 
in which they occur. 

Sect. I. — General View of the Modes of Diseased Action 
observed in Diseases of this class. 

Disordered states of vital action in individual parts of 
the body require to be studied, and indeed are often 
regarded as constituting separate diseases, not only when 
they take place idiopathically, but also when they take 
place symptomatically, in consequence of other diseases, 
— sometimes of distant parts of the body, — if they are of 
such intensity as to cause much suffering or danger. 

The most important of the modes of diseased action 
observed in chronic diseases may be ranked under the 
following heads. 

I. The fundamental function of Involuntary muscidar 
action may be either simply in excess — or deficient — or 
may be performed irregularly ; or it may be easily ex- 
cited, but either act feebly from the first, or quickly fail 
in energy, — the mode of action described by CuUen under 
the name of Mobility, more frequently designated of late 
years under the name of Irritation, or Prostration with 



OF CHKONIC OK NON-FEBRILE DISEASES. 503 



Excitement. All this is occasionally seen in the actions 
of the Heart, Alimentary canal, and Bladder. 

In the case of the Heart, these varieties may be from 
excess or defect of the natural stimuli, or from stimuli 
applied in an unusual manner (as in the very common 
case of inflammation on the internal lining membrane 
of one of these muscles exciting increased action and ul- 
timately hypertrophy) ; or they may result from changes 
in, or impressions on, the nervous system, affecting the 
property of irritability in these muscular parts. Al- 
though seldom constituting the whole pathology of indi- 
vidual cases of disease, they are very often the main 
objects of practice in various diseases, as the affections 
of the heart belonging to this class are sometimes the 
cause of immediate and imminent danger. 

II. The Circulation in the capillary vessels is subject 
to various morbid changes, independently of inflamma- 
tion. In such cases, however, as in inflammation itself, 
any changes that take place in the contractile power of 
the vessels, are more probably the effect than the cause 
of the altered flow of blood ; so that local determination 
or congestion, although the most prominent symptom, 
is seldom the most fundamental change. 

Local Determinations and Congestions, however, are 
a frequent change, and even when not the most funda- 
mental, form great part of the pathology of many chro- 
nic diseases, especially of the mucous meml)ranes, and 
of the parenchymatous viscera, including the brain; al- 
though, in the latter organ, we know from Physiology, 
that it is the impetus of the blood, and the rapidity of 
its transmission, not its quantity, that is chiefly liable to 
alteration. 



504 OUTLINES OF PATHOLOGY AND PRACTICE. 



Such local plethora is most easily produced in child- 
hood or early youth in the head and nose ; after the 
growth of the body is over, in the lungs ; in women, during 
the time of menstruation, in the uterus ; in advanced life, 
either in the head or in the abdominal vessels, especially 
the hemorrhoidal, and in different individuals in diffe- 
rent parts of the body, either from innate peculiarities or 
habits, or previous disease. 

Determinations are often produced by local irrita- 
tions, physical or mental, of less intensity than those 
which excite inflammation, and which generally act pri- 
marily on the chemical phenomena of the body ; there- 
fore at the extremity of the arteries. They are favoured 
remarkably by various causes, important to be noted, 
whose action is chiefly mechanical, either increasing the 
afflux by the arteries, or obstructing the return by the 
veins ; especially by the following, — General plethora, 
Suppression of usual evacuations. External heat. Exter- 
nal cold. Muscular exertion of the whole body or of in- 
dividual parts, Position, Ligatures. They are peculiarly 
favoured also by the effect of organic disease, previously 
existing, on the circulation, — as by obstruction in the left 
side of the heart, causing congestion in the lungs ; or by 
obstruction on the right side of the heart, or in the lungs 
(frequently occurring in all diseases of the lungs) caus- 
ing congestion in the head ; or by impediment to the 
flow of blood in the lungs or heart, causing congestion 
in the liver; or in the liver causing congestion in the 
mucous membrane of the bowels ; or by any morbid 
growth in one part of an organ, as the brain or lungs, 
favouring congestion and its consequences, particularly 
haemorrhage, in other parts of the same. 

Suck causes of local plethora either cause or aggra- 



OF CHRONIC OR NON-FEBRILE DISEASES. 505 

vate disorder of tlie functions of various textures, es- 
pecially of the nervous system, or of the different or- 
gans of secretion ; and are therefore to be carefully 
kept in view in all disorders of those parts. This is 
sufficiently shewn by the connection of such disorders 
with, or their ready transition into, heemorrhagic or in- 
flammatory diseases, and by the juvaniia et Icedentia 
ill them. The evidence of the existence of such local 
plethora on dissection is often fallacious, the distri- 
bution of blood in the small vessels, after death, being 
liable to variety from various causes; and it is cer- 
tain that local plethora, particularly in the brain, may 
so impair the function of parts as to be fatal, nearly 
as mechanical injury is, without leaving any decided 
mark; but it is often followed, and unequivocally in- 
dicated, either by Haemorrhage or by Dropsical eff'usion, 
both of which may be regarded as originating in mere 
increase, with slight alteration, of the exhalations of the 
parts,— therefore as functional disorders only, imply- 
ing no change in the chemical phenomena of the body. 
The lesions of texture produced by haemorrhage are in 
general easily recognised and distinguished from all 
other organic diseases. 

Both haemorrhage and dropsical effusion are, as may 
be judged from the above, very often the results of pre- 
viously existing organic disease; but both are in them- 
selves sufficient to cause such impediment to the func- 
tions of the parts where they occur, — and haemorrhage, 
from any free surface, may produce such failure of the 
circulation, — as may be fatal, on the principles formerly 
explained ; they are therefore proper objects of practice, 
and are properly regarded as constituting in themselves 
important diseases. 



506 OUTLINES OF PATHOLOGY AND PRACTICE. 



III. Affections of the Secretions^ properly so called, 
constitute the most essential part of many functional 
diseases, deviating from the external state either by ex- 
cess, or defect, or by alteration of qualities. These 
diseased states may be conveniently arranged thus : — 

1. The mucous secretion, destined only for the />ro^6c- 
tion of the surfaces where it is throvn out, is liable to all 
the variations stated above, and especially to morbid in- 
crease of quantity; and thence arise various diseases, 
which may be troublesome or dangerous, partly by in- 
juring the functions of the parts, or of other parts con^ 
nected with them, but chiefly as a general evacuation, — as 
in Leucorrhoea and Diarrhoea mucosa, approximating to, 
but often quite distinct from, the effects of chronic in- 
flammation. 

2. The recrementitious secretions of the alimentary 
canal, requisite for the digestion and assimilation of food, 
particularly the Bile, may be increased to such a degTee 
as to weaken or endanger the system (as in Cholera), in 
like manner as is done by simple diarrhoea ; but the chief 
functional diseases, in which these secretions are con- 
cerned, are the result of deficient or altered secretion, 
as in the diflerent forms of Dyspepsia, constipation, the 
torpid condition of the liver, and several kinds of Jaun- 
dice, among others, that proceeding from gall-stones. 
Such alterations of the secretions, resulting from various 
causes, to be afterwards noticed, have various bad ef- 
fects, sometimes strictly local (as in the case of jaundice 
from gall-stones), sometimes on the sensations and other 
functions of the nervous system, and often most seriously, 
on the act of assimilation and on the constitution of the 
blood. Hence the symptoms residting from this kind 
of disorders, and the other diseases which may super- 



OF CHRONIC OR NON-FEBRILE DISEASES. 507 



vene on them, are remarkably various and often obscure. 
The change of the secretions in such diseases is pro- 
bably seldom the most fundamental change ; but it pre- 
cedes and causes the change in the flow of blood to the 
part, and it produces changes in the sensations and other 
affections of the nervous system (just as happens in in- 
flammation), and is often, therefore, the immediate cause 
of the most prominent symptoms. 

3. Another class of these functional diseases consists 
in, or shews itself by, changes of the different kinds 
above stated, in the ea:cretions, particularly that by the 
kidneys, that by the liver, and that by the uterus ; the 
natural state of these excretions, especially of the first, 
being equally requisite (whether as causes or as indica- 
tions) to the healthy state of the blood, as the action of 
the gastric juice on the aliments. 

W e have examples of this kind in the formation of 
the different kinds of Gravel, and in the Diabetes, both the 
insipidus and the mellitus, which are pretty clearly traced 
to changes in the action of assimilation, and in the consti- 
tution of the blood, — not, strictly speaking, to morbid 
actions of the kidneys themselves. Such diseases are 
likewise dangerous or fatal, sometimes by their local 
effects, sometimes by the sympathetic changes, particu- 
larly in the nervous system, which they produce ; but 
chiefly by reason of the morbid condition of the blood, 
of which they are the result and indication, and which 
aids in producing various other local noxious effects. 

The great increase of excretion, particularly in the 
case of Diabetes, and sometimes of Menorrhagia, is dan- 
gerous, simply as an exhausting evacuation ; and, on the 
other hand, in the case of absolute retention of excre- 
tions, as in one kind of Jaundice, in Ischuria renalis, or 



508 OUTLINES OF PATHOLOGY AND PRACTICE. 



even in Amenorrhoea, we have unequivocal examples of 
local functional disease, so altering the constitution of 
the blood as to make it act on the body on the footing 
of a dangerous or even inevitably mortal poison. 

4. There is yet another set of disorders usually re- 
garded as functional, because not implying any organic 
change in the solids^ and which may be considered here, 
because they indicate alteration of the general function 
of assimilation, viz., those which depend on a morbid 
condition of the bloody indicated by its own qualities in 
all parts of the body, but often leading to dangerous 
changes in individual parts. Plethora and Anaemia are 
the extremes as to the quantity of blood found in the 
body, and both are frequent causes or accompaniments 
and aggravations of local diseases. Scurvy and Purpura, 
or the Ha?morrhagic Diathesis, are cases in which the 
constitution and vital properties of the whole blood are 
altered^ in a way, likewise, often productive of local 
disease. These last cases approach to the nature of con- 
stitutional, even of malignant, organic diseases. 

The process of assimilation is too imperfectly under- 
stood to enable us to judge of the manner in which these 
morbid conditions of the blood are effected ; but we know 
that, besides being dependent on a natural state of the 
various secretions which have been mentioned, the che- 
mical changes continually occurring in the circulating 
blood are much regulated by the quantity of oxygen re- 
ceived in respiration, and by the rapidity of the motion 
of the blood as affected by exercise ; and farther, that 
they are remarkably under the influence of changes in 
the nervous system, particularly of those connected with 
pleasing or painful sensations, and with exciting or de- 
pressing passions of mind. 



or CHRONIC OR NON-FEBRILE DISEASES. 509 



IV. Another important class of Functional diseases 
consists of affections of the Nervous System^ which are, 
of course, unknown in their own nature, but shew them- 
selves chiefly in the following ways : — 

1. By various uneasy Sensations ; some local, others 
pretty general over the body, which are known to occur, 
in certain constitutions, independently of any lesion of 
structure in the Nervous System, — the different Neur- 
algic pains, — the Globus and other hysterical symptoms, 
— the suffusiones, and tinnitus aurium^ sense of internal 
heat, &c. 

2. By various Spasms^ known, in like manner, to be 
often unconnected with organic disease, occurring in the 
voluntary muscles in different parts — sometimes locally, 
sometimes more generally — in the muscles of Respira- 
tion, or in portions of them, as in Spasmodic Croup, or 
Asthma, Hiccup, certain forms of Hysteria ; or in the 
muscles of the limbs, as in certain Convulsions of infants, 
the Chorea of older children, the aggravated forms of 
Hysteria in adults. 

3. By various affections of the llental faculties them- 
selves, likewise known to be functional and transient, 
often quickly transient, e. g. morbid excitement or depres- 
sion, spectral illusions, and various degrees of Hypochon- 
driasis, and even of Delirium, or hallucinations, partial or 
general. 

All these afifections of the nervous system frequently 
exist as effects of undoubted lesions of structure in its 
central masses ; frequently also as effects, at least partly 
as effects, of derangement of the flow of blood on the 
brain ; but in certain constitutions of unusual mobility, 
chiefly in women and children, all may occur indepen- 
dently of any such lesions, and may pass off rapidly and 



510 OUTLINES OF PATHOLOGY AND PRACTICE. 

completely ; — being excited in sutjli cases either by causes 
purely mental, or by impressions made on tbe extremi- 
ties of sentient nerves, as in the teeth, mucous mem- 
brane of the stomach and intestines, or surface of the 
body, — to which case the term Excentric affection of the 
nervous system has been lately applied ; or occurring 
without obvious cause. In such constitutions we know 
that even absolute Coma, or suspension of the functions 
of the brain, may sometimes occur repeatedly, and last 
long, simply as a functional disease. 

This enumeration of functional disorders sufficiently 
indicates that they must be very frequently blended or 
combined with each other, and with inflammatory or 
with organic diseases ; and that any formal classifica- 
tion of them may easily mislead us in practice. 

Sect. II. — General view of the hinds of Morbid Struc- 
ture observed in Diseases of this class. 

These may be divided into three great classes, to all 
which the term Organic disease is applicable. 1. Those 
which imply no formation of new growths. 2. Those 
which consist in the formation of new growths only in 
individual parts, and generally not consisting of matter 
foreign to the healthy composition of the body. 3. Those 
which consist in morbid deposits taking place in different 
parts of the body successively or simultaneously, and 
generally composed of heterologous matter, implying a 
vitiated condition of the fluids. All these varieties have 
been already so far under our view, because all may 
occur as results of Inflammation ; but there are many 
cases, of all kinds, which cannot be traced to this source. 



OF CHRONIC OR NON-FEBRILE DISEASES. 



511 



I. Of the first kind, the following demand particular 
study : — 

1. Hypertrophy^ or simply increased bulk of natural 
textures, resulting sometimes from lympli thrown out 
in them by inflammation, and gradually organized, as is 
seen occasionally in bones, glands, fibrous or mucous mem- 
branes that have been inflamed — sometimes from a spe- 
cific action of substances circulating in the blood on the 
nutrition of individual parts, as in the case of Bronchocele 
— more frequently from some morbid increase of the na- 
tural vital action carried on in a part, implying increased 
attraction of the blood and nutrition there ; as when 
hypertrophy of the Heart, or of any portion of it, fol- 
lows any obstruction to the exit of blood — hypertrophy 
of the Stomach, obstruction at the Pylorus — hypertro- 
phy of the Bladder, obstruction at the prostate gland or 
urethra — or hypertrophy of the muscular coat of the 
Intestines, any impediment to their peristaltic move- 
ment ; — or, again, when disease of one Lung, or of one 
Kidney, leads to great increase of bulk, without change 
of texture, in the other. 

Such instances of hypertrophy, although often ranked 
as diseases, are in fact examples (as formerly noticed) 
of the healing provisions of Nature ; but in other cases 
hypertrophy of natural textures, of the heart, of bones, 
of the spleen, perhaps more frequently of the substance 
of the brain, occasionally even of whole limbs, takes 
place without any such obvious cause, and constitutes in 
itself a real disease. 

2. Atrophy of living textures, sometimes resulting 
from an increase of absorption, consequent on inflamma- 
tion, or more frequently of pressure, is often also the 
effect merely of disuse of parts (the converse of what 



512 OUTLINES OF PATHOLOGY AND PRACTICE. 

was noticed as to hypertrophy), as in Muscles wasting, 
or whole limbs stunted in their growth, from long con- 
tinued rest, or Nerves of sensation (especially tbe optic) 
wasting from inaction, as from opacity of the cornea. 
And in other cases, particularly in young children, we 
see imperfect nourishment of organs, or of whole limbs, 
without obvious cause. 

3. The form, and ultimately the vital action, of organs, 
is in various cases, of great importance, liable to simply 
mechanical change^ by at least a process in the first in- 
stance, mechanical, although afterwards vital, chiefly im- 
plying increased absorption, in consequence of disease of 
neighbouring parts. Thus in a feeble habit, passive 
aneurism, or Dilatation of the heart (remarkably of the 
right side in cases of habitual asthma), results from ob- 
struction to the exit of the blood. Aneurism of Arteries, 
although always originating in a diseased state of the inner 
membrane of arteries, is a change chiefly efl'ected by the 
mere pressure of the blood, causing distension of the outer 
eoats ; and Varix of the veins, seems to be eff'ected almost 
exclusively in this way. Emphysema of the Lungs, de- 
pendent on dilatation and rupture of the air-cells, seems 
to be always the mechanical result of their forcible com- 
pression, by the acts of expiration and of coughing, at a 
time when the exit of air by the bronchia is impeded by 
the efl"ects of inflammation and spasm. This is most 
easily produced in early youth, when the texture of the 
superficial parts of the lungs is soft, and again in old age, 
when it is comparatively bloodless and brittle. Dilatation 
of the Bronchiae seems to be merely the result of habitu- 
ally increased secretion of mucus in them, — probably espe- 
cially when the adjoining portions of lung are consolidated 
and motionless. Dilatation of the ureters, pelvis, and 



OF CHEONIC OR NON-FEBRILE DISEASES. 513 



calices of the Kidneys, and ultimately absorption of the 
substance of the kidneys, result from any obstruction to 
the descent of the urine. Gradual unfolding of the convo- 
lutions of the brain from Hydrocephalus is partly effected 
in this way ; the formation of the small encysted tumors 
called Meliceris on the surface of the body, and of Kanula 
under the tongue, is, in like manner, owing to the dis° 
tension of obstructed parts ; and the partial expansion of 
the fibres of bones to form the kind of tumour called 
Spina Ventosa, is to be ascribed to the pressure of mor- 
bid growths from their medullary membrane, 

4. Softening of living textures, with more or less of 
change of their composition, independently of previous 
inflammation, sometimes takes place merely by perver- 
sion of nutrition, and without change of colour, and they 
are thus partially and somewhat variously unfitted for 
their function. This is seen in the nervous substance, 
in the liver, spleen, and kidneys, perhaps less frequently 
in the lungs, occasionally in the muscles, chiefly the 
involuntary, and remarkably in the mucous membrane 
of the stomach, and in the internal lining membrane of 
the arteries. The most remarkable example is the ge- 
neral softening of bones, and, indeed of all textures, 
which constitutes the tickets of children, seen also in 
some cases of Mollities ossium in adults. 

5. Hardening^ or even ossification of lining textures, 
takes place frequently, likewise, altogether independent- 
ly of inflammation, simply by increase of the proportion 
of certain of the deposits always taking place there, as 
in arteries, — chiefly in advanced life, but by no means 
uniformly even in different parts of the same person— 
in the liver and kidneys, — sometimes in the muscles, or 
in the cellular sheaths of muscles, occasionally in va- 



514 



OUTLINES OF PATHOLOGY AND PEACTICE. 



rious parts of the fibrous texture, and not unfrequently 
in the brain and nerves. Such transformations as the 
fatty degeneration of the liver, or less frequently of 
the heartj are in like manner to be regarded as altera- 
tions of the relative proportion of constituents in the 
natural nutrition of these organs, not as morbid growths. 

Some of these last changes, however, in the compo- 
sition of the textures (e. g, that which occurs in Rickets), 
evidently imply a faulty composition of the blood, or a 
morbid state of the processes by which, in its circulation 
through the body, it is continually changed ; and their 
pathology, therefore, seems to approach very closely to 
that of the constitutional, and even malignant morbid 
growths. Such changes, accordingly, are attended not 
only with injury to the functions of the parts where they 
take place, but with constitutional disorder or debility ; 
but the merely local lesions now enumerated, are inju- 
rious only, inasmuch as they affect the functions of the 
individual parts. 

11. Of Morbid Growths, not constitutional, nor com- 
posed of heterologous matter, we may make the following- 
arrangement : — - 

1. There are a variety of Encysted tumors, from the 
simple serous cyst, often seen on the surface of the 
kidney, to the clusters of hydatids, — to the encysted 
dropsy, e.g. of the O vary,— or theSteatoma, or Atheroma 
(according to the appearance and consistence of its con- 
tents), which may form in any cellular texture ; and 
there is much variety in the contents of these cysts, and 
the structure of the sacs containing them. 

2. These graduate into the Sarcomatous tumors, 
usually divided into lobules, by cellular membrane, and 



OF CHRONIC OR NON-FEBRILE DISEASES. 515 



likewise consisting of congeries of cells, containing a 
semi-fluid, or solid matter, but in which these cells are 
smaller and more numerous, and the vascular septa 
penetrate the substance more completely, than in the 
encysted tumors. To this class belong, not only the 
common vascular Sarcoma, but one kind of the Polypus, 
the Adipose Sarcoma, the Neuroma (where the peculi- 
arity seems to be merely, that the tumor grows within 
the sheath of a nerve, and separates and stretches its 
fibrils), the Chondroma, or Fibro-Cartilaginous tumor, 
and the Osteo-Sarcoma, which contains much bony de- 
posit. In some cases the variety in the constituents of 
these tumors seems to depend on the variety of the tex- 
tures in which they form, but in others, almost all these 
varieties may be seen in a single tumor, or in tumors de- 
veloped in similar parts. Such purely local diseases 
are often stationary for a considerable time, and when 
not so situated as mechanically to impede some im- 
portant function, may last long, without injuring the 
general health. 

III. Those tumors which consist of " heterologous 
matter," foreign to the natural constitution of the body, 
are not always, in their origin, to be distinguished, either 
from such structures as have been now described, or 
from the products of inflammation ; and such tumors 
may originate from local causes, and go to a certain 
length, without implying such alteration of the fluids 
as leads necessarily to their reproduction in other parts. 
But in general, we can distinguish them by their ap- 
pearance, as well as by their history and progress ; and 
may expect^ in regard to deposits of this kind, to find, 
that they originate nearly simultaneously at different 



516 OUTLINES OF PATHOLOGY AND PRACTICE. 

points, whether of the same or different organs, and that 
their deposition extends to different parts of the body, — 
often shewing a remarivably syinmetrtcal arrangement, 
particulariy in double organs, as the kmgs or kidneys 
at the same time that an irregular infiltration of the 
matter composing them, often takes place in the imme- 
diate neighbourhood of the parts where the first tumors 
are developed. In many instances the adventitious 
matter, forming such tumors, shews itself in swellings of 
lymphatic glands, in the neighbourhood of affected parts ; 
and in some it is clearly detected in the veins leading 
from these parts ; and the contamination of the blood 
by the matter composing them is clearly shewn, not 
only by these facts, but by the frequent appearance or 
increase of disease, depending on such deposits, in inter- 
nal parts, soon after the amputation of limbs, or re- 
moval of other external parts, in which they had shewn 
themselves ; just as was formerly observed, in regard to 
cases where purulent matter (healthy or scrofulous), has 
been undoubtedly formed within the bloodvessels, or 
been taken into them. 

The multiplication of such adventitious or heterolo- 
gous matters in the blood, and their dissemination through 
the body, has certainly a strong analogy, although one 
that is as yet imperfectly investigated, to the putre- 
faction of organized matters, and the reproduction of 
animalcules ; to the phenomena of the febrile contagious 
diseases, and likewise to the regulated growth of all 
living textures, by the development and reproduction of 
nucleated cells. 

This general description applies to many kinds of de- 
posits from the blood, more or less distinct from any 
* See Budd in Medico- Chirurgical Transactions. 

3 



OF CHRONIC OR Ndx-FEBRILE DISEASES.^ 517 



thing which is formed from it in the healthy body, all 
of which often appear as the results of inflammatory 
action, but appear also, often in a more symmetrical 
form, without any inflammatory symptoms. From the 
facts above noticed, in regard to them, it may be infer- 
red, that they have all a constitutional origin, and imply 
a morbid condition of the blood ; but they do not all 
equally tend to rapid extension, and invasion and destruc- 
tion of neighbouring textures, or to uniform or continu- 
ous increase, — nor are they all equally incapable of 
being aff'ected by remedies or regimen ; and hence, al- 
though all Constitutional diseases, they are not equally 
regarded as Malignant, 

Such deposits from the blood vary, in diflerent in- 
dividual cases, so as hardly to be easily reduced to ge- 
nera or species j but the greater number of them may 
be ranked under the following heads :— 

1. The Scrofulous Tubercles, already considered, — 
sometimes deposited very partially, and then admitting 
of transition to a very inert state, in which they may 
continue nearly innocuous for many years, — more fre- 
quently extending with various rapidity, passing in 
some parts, especially where exposed to air, into sup- 
puration and ulceration, and becoming attended with 
hectic fever. 

2. The Gh^anular deposits, — considerably various in 
different cases, — which lay the foundation of the Cirrhosis 
of the Liver, of Bright's disease of the Kidneys, and 
of many degenerations of the middle and inner coats 
of the arteries, and valves of the heart ; thereby pro- 
ducing the most common organic diseases of those parts, 
and deranging or obstructing their functions, in like 

PART III. L 1 



518 



OUTLINES OF PATHOLOGY AND PRACTICE. 



manner as is done by the distinct results of chronic in- 
flammation of those parts, ah'eady considered. 

3. The rarer deposit of soft matter, sometimes en- 
cysted, sometimes not, which, from its black colour, has 
the name of Melanosis ; which is often very generally 
extended, but has less tendency to invade and alter the 
surrounding textures, and which seems to consist in 
the deposition of the colouring matter of the blood, so 
little changed, that it may be said to graduate into the 
case of Purpura, or the Heemorrhagic Diathesis. 

4. The irregular, but usually encysted deposits, larger, 
of whiter colour, usually softer (although in that respect 
there is much variety), and probably always of more 
rapid growth than either the tubercles or the granules, 
to which the term Encephaloid matter is usually ap- 
plied, and which form occasionally in almost all parts 
of the body, and affect their functions, in like manner 
as the last mentioned diseases. When the matter de- 
posited is more firm, and at the same time fatty, the 
term Lardaceous, and when more translucent and gela- 
tinous in appearance than usual, the term Colloid, has 
been applied to it. 

5. The firm, hard, usually somewhat fibrous deposits, 
distinguished as the true Scirrhus, seen almost exclu- 
sively in certain very vascular parts of the body, — the 
lips, tongue, cardia, pylorus, caecum, lymphatic glands, 
glans penis, testes, and especially the mammse and os 
uteri, — slower in their progress than those last men- 
tioned, but equally sure to contaminate, soon after they 
commence, both the neighbouring parts, and the blood 
generally; and passing more surely than any of the others 
into the peculiar fungous and intractable ulceration, to 
which the term Cancer has been often restricted. 



OF CHEONIC OR NON-FEBEILE DISEASES. 519 



It is especially to the two last of these kinds of mor- 
bid structures, — from the certainty with which they in- 
vade the neighbouring parts, and extend themselves 
over the system, and their uniform tendency to increase, 
until they extingidsh life in one way or other, — that the 
epithet Malignant has been usually applied in this coun- 
try, and the term Cancer in France ; but their diagnosis, 
either from the effects of inflammation, or the other less 
formidable organic diseases, is often impossible in the 
early stage ; and, when they are situated internally, is 
to be made out, as the disease advances, rather by ob- 
servation of the state of the general health, than of any 
of the local symptoms. 

From what has been said of their frequently origi- 
nating in, or being repeatedly aggravated by, inflamma- 
tion, and from what has been formerly said of change of 
functions, and among others of secretions, in internal 
parts, forming great part of the symptoms of inflam- 
mation there, it will readily be understood, that the 
symptoms of organic diseases in internal parts should 
in general very closely resemble, and often be hardly 
distinguishable from, those of the more chronic inflam- 
mations of the same parts, or of the altered secretions 
of these, already considered. Indeed it is often only 
by the continuance of the complaint, by the experienced 
inefficacy of ordinary remedies, and by the increasing 
weakness and emaciation attending it, that the existence 
of Organic Disease is made known. 

It may be stated in general, that Pain is little to be 
depended on as a mark of organic disease. It may be 
felt strongly when there is no such disease, and be in- 
tense wdien such disease is shght, as when the fibres of 
a nerve are compressed or stretched ; it may be absent 



520 OUTLINES or PATHOLOGY AND PRACTICE. 



when the disease is very dangerous ; and although the 
most malignant organic diseases are often attended with 
acute pain, yet it is usually liable to great and long remis- 
sions. It is very often to be regarded, therefore, rather 
as an accidental concomitant, than as an essential con- 
stituent of such diseases. And in general, these dis- 
eases are to be recognised much more by alterations of 
sensible qualities, or derangement of functions, which 
may be detected by the senses of the practitioner, than 
by such uneasy sensations as are known only through 
the complaints of the patient. This observation is of 
great importance in reference to cases where organic 
disease may be suspected, but where the tendency to 
hysteria or hypochondriasis exists. 

Sect. III. — General View of the Causes and History 
of these Chronic Diseases^ and of the Objects of Prac- 
tice in regard to them. 

Many of these diseases appear to be almost unknown 
in the earlier stages of human society, and must be as- 
cribed chiefly to certain results of civilization ; which 
makes the study of their causes particularly important ; 
giving us reason to believe that they may often be pre- 
vented or controlled by human wisdom and prudence, 
exerted either in individual cases, or in devising such 
political regulations as recognise the obligation of Govern- 
ments to provide, as far as possible, " ut cives feliciter 
vivant." 

Referring to what was formerly stated as to the falla- 
cies attending the evidence by which we judge of the 
power of the remote causes of disease, we next observe, 



OF CHRONIC OR NON-FEBRILE DISEASES. 



521 



tbat, in the production of these, as of other diseases, dif- 
ferent causes generally concur, which may be ranked, 
though somewhat vaguely, as Predisponent and Exciting ; 
and most generally the former class of causes seem to 
act by affecting the constitution of the Blood, and the lat- 
ter by affecting the Nervous system ; through both which 
channels we consider it certain that all vital actions may 
be influenced. Many of these causes are the same as, 
when acting in a higher degree of intensity, produce in- 
flammation, or concur in producing strictly febrile dis- 
eases ; and it may be said in general, that the causes of 
Chronic disease, and in many instances the existence of 
such disease, give a predisposition to Acute disease. 
We must allow that we have very little information 
as to the circumstances which determine one form of 
disease in one case, and others in other cases, from the 
application apparently of the same causes. 

The blood appears to be so altered in constitution as 
to be rendered a cause of disease : 

1. By improper aliments, either defective in quantity, 
or excessive, or unfitted for due assimilation. 

2. By truly poisonous matters {e. g, alkohol) intro- 
duced from without with the aliments, or by the lungs. 

3. By poisonous matters formed and retained in the 
body itself, though destined for excretion. 

4. By a defective or altered condition of those secre- 
tions which are immediately concerned in the assimila- 
tion of food. 

5. By a defective or altered state of other vital actions 
requisite for the assimilation of aliments, particularly of 
respiration, as affected by the quality of the air breathed, 
and of circulation, as excited by the natural stimulus 
of exercise. 



522 OUTLINES OF PATHOLOCxY AND PRACTICE. 



6. By other causes of excessive or deficient quantity 
of blood in individual parts, besides tbe nature or due 
preparation of the ingesta, e, g, such causes of local 
plethora as are stated above (p. 4), or such causes of 
locally defective circulation, as previously diseased or 
obstructed arteries. 

7. By causes, not yet understood, acting in individual 
parts of the body, and altering the constitution of the 
blood there in the first instance, which alteration is sub- 
sequently extended; as in inflammation, in tubercles, 
cancer, &c. 

8. By causes not yet understood, but which afl'ect 
the vital properties of the whole blood, as is seen in cases 
of Purpura or the Heemorrhagic Diathesis. 

In all these cases it is a vital, not a simply chemical 
action, which is originally in fault, although in several 
a chemical change in the constitution of the blood, or 
of some of the secretions, results from, and indicates 
that altered vital action. 

In several of these cases, it is probably through the 
intervention of the Nervous System that morbid changes 
are effected in the blood ; and the following are cases in 
which impressions on, or changes in, the nervous sys- 
tem, are certainly and directly concerned in producing 
local diseases in different parts of the body ; even when 
we have reason to believe that the constitution of the 
blood is quite healthy at the time when the diseased 
actions commence. 

1. When impressions causing pain or uneasy sensa- 
tion are made on the sensitive nerves of individual parts, 
by a sympathetic or reflex action, various morbid phe- 
nomena — sometimes of the nerves and muscles, some- 
times of the capillary circulation and secretions, — are ef- 



OF CHBONIC OR NOX-FEBEILE DISEASES. 523 



fected in individual, but often in distant parts of the 
body, as in the case of the teething of infants, the worms 
of children, the tetanus, or some cases of the dyspepsia 
or diarrhoea of adults. It has been already stated that 
the action of certain poisons, when most rapidly affecting 
the body, seems to be of this kind. 

2. "When causes are applied which excite excessive 
and uneasy sensations, apparently affecting the whole 
system, these frequently excite morbid phenomena, just 
as in a less degree they excite healthy actions, in indivi- 
dual parts only ; as in the case of Heat exciting particu- 
larly the actions of the liver; Cold exciting those of the 
heart or of the mucous membrane of the intestines ; 
Nausea, from impressions made on the nervous centres 
themselves, exciting the secretions of the mouth, and 
the actions of the diaphragm and abdominal muscles ; 
or any Sensation very long continued, and therefore be- 
coming irksome and uneasy, gradually depressing the 
heart's actions. 

3. In many instances, voluntary muscular exertions, 
excited through the nervous system, are more direct 
causes of disease by their effect on the circulation, as 
in cases of haemorrhage excited by exertion of various 
kinds. 

4. When certain emotions, either the violent excitinof 
emotions, such as anger or joy, or the long-continued 
depressing emotions, anxiety, vexation, or despondency, 
strongly engross the mind, they very frequently pro- 
duce or co-operate in producing, much more extended 
and injurious effects, often not easily traced to their 
true source ; in the vital actions of muscles, voluntary 
or involuntary, and in all the secretions, especially those 
which are most immediately concerned in the assimi- 



524 OUTLINES OF PATHOLOGY AND PRACTICE. 



latioii of food. The most striking example is the pro- 
duction of fatal jaundice by suppression of the secretion 
of the liver, resulting from mental emotion, and inde- 
pendent of any obvious change of structure. 

In these different modes, changes which we believe to 
originate in the nervous system, become causes, some- 
times predisponentjbut more frequently exciting, of various 
non-febrile diseases, both of those of which the chief symp- 
toms are in the functions of the nervous matter itself, 
and of those in which involuntary motion, secretion, or 
nutrition, are more obviously deranged. Referring to 
the enumeration given (at p. 51 to 61 of Part I. of the 
Outlines ) of the chief individual causes of disease, inde- 
pendent of the application of morbific poisons, which 
afflict humanity, we may here take a practical view of 
those included in that enumeration, which are most in- 
fluential in exciting chronic disease ; distinguishing them 
according to the ranks of society, and the periods of life, 
in w^hich they chiefly take effect. 

In the lower ranks of society, and in the early periods 
of life, the great causes of disease are j>rivations^ some- 
times of sufficient or of adequately nutritious aliments, and 
of adequate protection against cold, — and more frequent- 
ly of the pure air, exercise, and mental excitement re- 
quisite for the due assimilation of aliments. This ap- 
plies particularly to the case of children in towns, and is 
sufficiently illustrated by comparing their condition with 
that of those of the same rank brought up in the country. 

In more advanced life, the following are the chief 
causes of disease afl*ecting the lower orders, which are 
superadded to those now mentioned : — 

1. Excessive muscular exertion. 

2. Intemperance as to strong liquors. 

3. Other vices. 



OF CHEONIC OK NON-FEEEILE DISEASES. 525 



4. Mental anxiety and depression, particularly from 
want of employment. The effects of all these are often 
very much increased by irregularity of life, particularly 
as to the time of taking food, and of sleep. 

By these causes we believe that the constitution of 
the blood, and the vital action, and probably the minute 
structure, of the nervous matter, are deteriorated ; and 
then the effect produced is extended and perpetuated by 
hereditary disposition. 

Again, in the higher ranks of society the following 
are the chief sources of chronic disease : — 

1. In childhood there is often a deficiency of exercise, 
of mental excitement, and of the tonic influence of fre- 
quent changes of temperature. 

2. In youth there is often over-excitement of the 
nervous system by mental influences, combined with de- 
ficient exercise. 

3. Next, there is often intemperance of various kinds, 
afiPecting variously the function of digestion, the circu- 
lation, and the nervous system. 

4. In many there are too sedentary occupations, or 
only occasional and irregular muscular exertion, such as 
may excite disease rather than contribute to health. 

5. In many there is, as life advances, want of mental 
excitement and interest, along with want of exercise, 
especially in women. 

6. In others there is excessive exertion, mentally and 
bodily, deficiency of sleep, and mental anxiety. 

7. In many there is, independently of intemperance, 
Repletion, and Plethora from excess of food, and some- 
times of sleep_, and defect of exercise. 

The morbid tendencies thus produced are likewise 
extended by hereditary transmission. 



526 OUTLINES OF PATHOLOGY AND PRACTICE. 



Although there is here much want of precise infor- 
matiou, yet the principles now stated are sufficient to 
point out many important means of prevention of Chronic 
diseases ; — in many instances applicable, in a certain de- 
gree, after these have already shewn themselves ; and 
the more important, as the power of remedies over them 
is very limited. 

In most of the Chronic diseases, however, as well as 
in the Febrile diseases, we see a strong tendency to a 
spontaneous favourable change, although taking place 
much more slowly and less regularly. The diseased 
actions are almost always only of temporary duration ; 
and even in the case of the malignant diseases, remark- 
able intermissions of the activity of their growth and 
extension are observed. These favourable provisions of 
nature must always be held in view, and may often 
suggest caution as to the use, or repetition, of any active 
remedies. 

The objects of practice in these diseases are, accord- 
ingly, different in the intervals, and during the continu- 
ance of their more decided manifestations. 

In the intervals, we are well assured (from observa- 
tion of the exciting causes of many attacks, and from 
our knowledge of the nature of the diseases) that much 
may be done to prevent returns or aggravation, by diet 
and regimen ; in many cases by such a modification of 
the antiphlogistic regimen as restrains fulness of blood, 
and prevents local determinations of blood, — still more 
frequently by such modifications of the Tonic Regimen 
{Outlines^ Part I. p. 80) as may fortify the system against 
many exciting causes of disease, — combined with such 
precautions as may prevent the application of others. 
These are the objects of many directions which are pro- 
perly given to individuals, and of many suggestions 



OF CHRONIC OR NON-FEBRILE DISEASES. 527 



which may be, with still more extensive good effects, 
made to legislatures or civil authorities. 

During the paroxysms or more active periods of the 
non-febrile diseases, we should first consider to what 
class they belong, and in what manner they may be ex- 
pected to become dangerous to life. The practice ought 
generally to vary according as they are merely functional, 
simply organic, or malignant. 

It is obvious from what was formerly stated (Part I. 
p. 79, et seq.\ that when disease is merely functional, 
we have various means, of very considerable power, of 
influencing it, by exciting or strengthening, or mode- 
rating, involuntary muscular action, especially that of the 
heart; by altering local determinations of blood; by ex- 
citing or by repressing different secretions and excretions, 
and thereby influencing both absorption and nutrition ; 
in a certain degree by directly influencing the function of 
assimilation and constitution of the blood ; and in a greater 
degree by exciting, depressing, or even specifically alter- 
ing certain actions of the Nervous System. But the 
power of all these, in Chronic diseases, is limited, and 
especially is temporary ; they have all, when used in 
a certain degree, injurious effects on the body; it is 
always to be considered how far they may interfere 
w4th the Tonic Regimen, which, in most such cases, is 
one of our main resources ; and the apparently frequent 
success of the Expectant practice, or of the Homoeopa- 
thic practice (which seems to be only a modern name for 
the same thing), ought to be viewed as a general warn- 
ing, that the provisions of Nature for the gradual de- 
cline of such diseases, under a judicious management 



528 OUTLINES OF PATHOLOGY AND PRACTICE. 



of regimen, are more efficient than many practitioners 
suppose. 

When we have ascertained the existence of organic 
disease, but have no reason to think it malignant, we 
should first reflect how far such disease, especially if 
merely local, is compatible with the endurance of life, 
or the enjoyment of tolerable comfort, and how far we 
have reason to expect that it can be directly affected by 
remedies or regimen. Next, we should consider what 
are the more temporary diseases, whether inflammatory 
or simply functional, that are most likely to complicate 
themselves with such permanent organic lesions, and 
render them immediately dangerous ; how these may - 
be prevented ; and when they occur, how soon, and how 
few_, remedies may be used to counteract them. 

In a few cases we can use remedies (deobstruents or al- 
teratives) with a fair prospect of directly influencing the 
morbid state of nutrition which is the foundation of such 
diseases, but the use of these remedies always demands 
special caution, on account of their ulterior injurious 
effects on the body, and their interference with the most 
material parts of the Tonic Regimen. 

In all chronic diseases, it is a part of our object, and 
in the case of the malignant diseases, especially in their 
advanced stage, it is the only rational object of practice, 
to palliate symptoms; counteract by evacuations, or other- 
wise, those parts of the diseased actions which are likely 
to cause the most distress ; to relieve uneasy sensations^ 
and study the means by which, in a large proportion of 
cases, the gradual increase of debility and approach of 
death may be divested of much of the suffering which 
would otherwise attend them. 



( 529 ) 



CHAPTER IL 

CHRONIC DISEASES OF THE AIE-PASSAGES AND LUNGS', 

The organs of Respiration, from the strength of the 
circulation in them, from their exposm'e to the air, and 
from their being comparatively little imder the influence 
of the ganglionic system of nerves, are less liable than the 
abdominal viscera to attacks of purely chronic disease ; 
most of their diseases, even when of long continuance, 
being directly or indirectly connected with inflammation. 
But in many cases already noticed, the more chronic 
forms of inflammation of these parts are attended either 
with functional or organic disease, of such intensity as 
to demand the chief attention of the practitioner ; as, for 
example, in the case of spasm of thebronchise, or asthma, 
and emphysema of the lungs, attending bronchitis ; and 
we have a few examples of functional and of organic dis- 
ease existing in these parts, altogether independently of 
inflammation. The most important cases of the latter 
kind are the following : — 

1. There are cases of Spasm of the muscles of theGlot- 
tis, producing difficult and crowing respiration, exactly 
similar to croup, but more sudden and more violent, 
which are unconnected either with fever or inflamma- 
tion. The most common case of the kind is the Laryn- 
gismus stridulus^ or crowing disease of infants, which at- 
tacks suddenly, almost always during or immediately 

6 



530 OUTLINES OF PATHOLOGY AND PRACTICE. 



after sleep, soon abates, but often rapidly recurs, al- 
though without cough, fever, or other marks of inflam- 
mation. In a few instances, a similar strictly spasmo- 
dic affection of the glottis occurs, and even habitually 
recurs, in adults. It is generally to be regarded as a 
merely functional disorder, excited or aggravated as 
many other spasms are, in peculiarly mobile constitutions, 
either by irritations acting at the extremities of certain 
nerves, especially the teeth of children, or the mucous 
membrane of the stomach or bowels, — or by causes acting 
as general irritants on the nervous system, such as men- 
tal emotion, or a determination of blood, however caused, 
to the head ; and the tendency to it often admits of relief, 
from moderate evacuations of blood, in plethoric habits, 
— from scarifying the gums, from purgatives and ant- 
acids, and to a certain degree, from antispasmodics, and 
medicines usually called tonics, e. g, assafoetida, espe- 
cially if used in glyster, musk, even opiates,— and vale- 
rian, oxide of zinc, or the arsenical solution. 

But in a considerable proportion of cases such fits of 
crowing respiration originate in a very different cause, 
viz. in stretching or irritation of the recurrent nerve (the 
motor of the larynx) by a tumour, generally within the 
thorax, which in a child may be the thymus gland or 
bronchial glands much enlarged, and in an adult is 
most frequently an aneurism. In the first of these 
cases, leeches, and other antiphlogistic remedies, and 
the cautious use of mercury or iodine, may be perma- 
nently effectual ; in the latter, a cautious regimen and 
repeated small bleedings are the only effectual pallia- 
tives, and will often avert one mode of fatal termination. 

2. There appear to be some cases of Haemorrhage from 
the fauces which appear to be functional only, z. e. taking 



OF CHRONIC DISEASES OF THE AIR-PASSAGES, &C. 531 



place by altered exhalation from the mucous membrane, 
admittmg of relief by the means to be stated presently ; 
but in many cases hsemorrhages, from this situation, are 
the result of aneurisms, which may have been previously 
unobserved. 

3. There are pretty numerous cases of the local 
symptoms, either of the most severe Cynanche Ton- 
sillaris, or Cynanche Laryngea, with occasional spasms, 
being very closely imitated by the growth of tumours 
in the fauces, at the edge of the glottis, or within the 
larynx, which are not inflammatory in their origin. 
Some of these tumours can be felt with the finger, but 
the greater number cannot. They sometimes gradually 
abate under the use of deobstruents, particularly of 
mercury, and sometimes demand the operation of tra- 
cheotomy; after which some subside completely, and 
others remain stationary, still obstructing the respiration 
through the larynx, but not affecting the general health. 
In other instances, however, they are of malignant cha- 
racter, and the patient sinks under the constitutional ir- 
ritation and exhaustion connected with their growth, even 
although the breathing should be relieved by the opera- 
tion. 

4. The cases of haemorrhage from the lungs, and of 
dropsical effusion into the cells of the lungs, or into the 
sac of the pleura, are often to be regarded as functional 
diseases, so far as the lungs are concerned ; but both will 
be more advantageously considered immediately, along 
with other hsemorrhages and dropsies, as diseased states 
of the capillary circulation, 

5. Besides the organic lesions of the lungs which re- 
sult from inflammation, and from deposition of tubercles, 
already considered, there are cases of organic disease of 



532 



OUTLINES or PATHOLOGY AND PRACTICE. 



the lungs and pleura, dependent on tlie deposition of hete- 
rologous matter, the melanosis, or the malignant encepha- 
loid matter, or some of its varieties. In most of these 
cases the morbid matter is partly, and in some it is solely, 
deposited in the bronchial glands. Such cases are attended 
with the usual symptoms of phthisis, and sometimes 
with those of chronic pleurisy ; and cannot be distin- 
guished from these with certainty during life, although 
the absence of the usual phthisical sputa, and the more 
general diffusion of the disease (as ascertained by aus- 
cultation), may give reason to suspect that the disease 
is not the usual tubercular phthisis ; and in many cases 
this opinion is confirmed by the better ascertained pre- 
sence of the disease in other parts. In all such cases, 
the palliative practice recommended for phthisis is our 
only resource. 



( 533 ) 



CHAPTER III. 

OF THE CHRONIC DISEASES OF THE HEABT AND 
BLOODVESSELS. 

We have here a mucli greater variety of disease, both 
functional and organic, independent of, or only partially 
connected with, inflammation. 

Sect. I. — OfCJironic Diseases of the Heart. 

The chief morbid states of the heart's action are de- 
ficient action, or Syncope, inordinate action, or Palpita- 
tion, and painful action, or Angina pectoris — all fre- 
quently symptomatic of organic disease, but occasionally 
idiopathic, and all acute diseases in point of duration, 
but non-febrile, and the tendency to which is usually 
quite chronic, and often intractable. 

I. The defective action of the heart demands parti- 
cular notice, both theoretically, as illustrating the im- 
portant connection between the nervous and vascular sys- 
tem in the living body, and practically, because although 
seldom existing idiopathically as the sole cause of dan- 
ger, it takes place in a certain degree, and constitutes a 
part of the danger, in many complex diseases, and we 
are necessarily very much guided in practising in these 
diseases, by the degree in which we believe the danger 
to result from this cause. 

PAET. TIL Mm 



534 



OUTLINES OF PATHOLOGY AND PRACTICE. 



Defective action of the heart, and threatening of 
death by syncope, is most essentially characterized by 
feebleness of pulse, and paleness and coldness of the sur- 
face, often attended by cold clammy sweats, and by mus- 
cular debility ; but in many cases, more striking symp- 
toms are presented by that change in the condition of the 
Nervous System, which is connected with the enfeebled 
state of the heart ; and there is great variety in the de- 
gree in which the Nervous System participates in the 
depressed state of the Vascular System, depending 
mainly on the degree of suddenness with which the de- 
pression of the heart's action is effected. 

When it takes place slowly^ the impetus of the blood 
on the brain and nerves being very gradually diminished, 
the Nervous System suffers in the first instance very 
little, and the pulse may become imperceptible, and the 
skin quite cold, before the senses are obscured, or the 
intellect sensibly impaired. The senses of sight and 
hearing are generally the first that are blunted in such 
cases ; but the mind is clear, — voluntary motions, though 
enfeebled, may often be performed with precision, — and 
the sensation which prompts to acts of respiration is so 
entire, that a heaving and laborious breathing is gra- 
dually produced, probably depending, not on any impe- 
diment to the access of air to the lungs, but simply on 
the increasing difficulty, with which the enfeebled heart 
propels the blood through the lungs. This is the state 
of the symptoms in many cases of disease (as of abdo- 
minal inflammation already considered), where there is 
imminent danger of death by syncope. In such cases, 
the pulsations of the heart, become usually more fre- 
quent as they become feebler. 

But when the heart's action is rapidly depressed, as 



OF THE CHEONIC DISEASES OF THE HEART, &C. 535 



by hsemorrhage, or violent mental emotion, the sudden 
diminution of tlie pressure on the brain and nerves, like 
other sudden changes in the condition of these parts, 
strongly affects the functions of the Nervous System ; 
and there is first vertigo, tinnitus aurium, confusion of 
thought, and then often an instantaneous loss of sense, in- 
tellect, and voluntary power, constituting what is called a 
complete fit of Syncope, even when the pulse is still quite 
perceptible, and before the surface has become cold. In 
such cases the diminution of sensation is often such, that 
the action of respiration may be nearly or entirely sus- 
pended for a time^ without any bad consequence. A 
sensation of anxiety and of nausea, prompting to acts of 
vomiting, and slight spasms of the voluntary muscles, are 
common accompaniments of the impression made on the 
Nervous System in such sudden syncope. The pulsa- 
tions of the heart, in this state, especially if the patient 
has previously been of strong habit, are generally slow 
as well as feeble. 

Thus, the insensibility of syncope is not merely a part 
of the general failure of vital action from a deficient 
supply of blood, but is to be ascribed to the slioch given 
to the nervous matter (of the medulla oblongata chiefly), 
by the diminished impetus, and perhaps by the sudden 
stagnation, of the blood. It is in the same way that 
insensibility is produced in children by weakening disease, 
especially Diarrhoea, in the cases to which the name of 
Hydrocephaloid disease has been given, while the pulse 
is still distinct at the wrist. 

There are some cases, usually called cases of Syncope, 
where the sudden loss of sense and voluntary power takes 
place, in nervous systems of peculiar delicacy, almost 
without alteration of the heart's action, and which in 
their pathology are more closely allied to Epilepsy. 



536 



OUTLINES OF PATHOLOGY AND PRACTICE. 



It has been already stated, that a sudden diminution 
of the pressure on the brain and spinal cord is itself a 
cause, not only of insensibility, but of weakened action 
of the heart ; and the impression made on the heart's 
action, especially in a feeble and irritable habit, by bleed- 
ing in the erect posture, as compared with bleeding in 
the horizontal, — or by rapidly assuming the erect pos- 
ture after stooping down, — is enough to establish this 
principle. 

When, therefore, we see a fit of Syncope, or a ten- 
dency to it, brought on either by loss of blood, or by 
purging, or sweating, or by alteration in the distribution 
of the blood, as by drawing off the fluid of ascites, we 
may reasonably infer, that the immediate cause of the 
complete failure of the heart's action is not the mere 
diminution of the stimulus acting on the heart, but a 
change in the condition of the Nervous System; just as 
it certainly is, when syncope is produced by strong men- 
tal emotions, — by certain long continued and unpleasant 
sensations, — such as particular odours or by intense pain, 
- — or the sudden transition from pain to ease, which are 
likewise frequent exciting causes of this affection. 

This secondary action or reaction on the heart, of di- 
minished pressure on the brain (originally consequent 
in some cases on deficient action of the heart itself), is 
very important to be kept in mind in all speculations as 
to Syncope ; and explains the well-known effect of the 
horizontal posture, not only on the nervous symptoms in 
syncope, but on the affection of the heart itself. This 
is one of the considerations formerly cited to prove, 
that, in the living body, the actions of the heart are 
subjected to an influence and control, from certain changes 
which take place in the nervous system ; and which 
seem to extend over the whole of that system, and act at 



OF THE CHRONIC DISEASES OF THE HEAET, &C, 537 



a peculiar advantage on the heart, as an organ connected 
through the ganglionic nerves, with all parts of the cere- 
bro-spinal axis.* 

The agency of all exciting causes of Syncope is greatly 
increased by circumstances of predisposition, — often by 
deficiency of the vital fluid, or general weakness of vas- 
cular action, as in convalescents from various diseases, 
or in persons exhausted by muscular exertion, or under 
the influence of sedative causes, as certain poisons or con- 
tagions ; often also by a peculiar state of excitability or 
mobility of the body, in which impressions from without 
peculiarly affect the nervous system, and affections of 
the nervous system are transferred with peculiar facility 
to other living parts, especially to the heart. It is thus 
that in women, especially of feeble and irritable habit, 
— about the menstrual period more than at other times, 
— in women affected with the slighter uterine diseases, 
and in persons labouring under long-continued mental 
depression or anxiety,^ — all the exciting causes of Syn- 
cope act with peculiar effect. 

The state of Syncope, occurring idiopathically, re- 
quires little treatment, except the horizontal posture, 
and dashing cold water on the face, or applying ammo- 
nia to the nostrils, to excite the action of inspiration. 
The tendency to Syncope, in various diseases, demands 
careful attention, and is our chief warrant for the use of 
stimulating remedies, wine, alcohol, ammonia, aroma- 
tics, volatile oils, &c., in small frequent doses ; and, when 
the stomach will admit of iU for the use of the tonic 
regimen. These means may ue used with good effect in 
a great variety of diseased states, when we are satisfied 

* See Physiology, 3d Edit, p, 400. 



538 OUTLINES OF PATHOLOGY AND PEACTICE. 



that there is immediate danger of death by Asthenia ; 
and the indication for them, in these circumstances, is 
of such importance, that it may be said to supersede 
all others. 

II. There are several varieties of Inordinate Action 
of the heart, unconnected with organic disease, which 
it is to no purpose to consider separately, because we 
know little of the causes of their difference. Such are 
permanently increased frequency, and sometimes ap- 
parent strength, of the heart's pulsations, with perfect 
regularity, and nothing unusual in the mode of contrac- 
tion ; or occasional violent fits of palpitation from exer- 
cise, mental emotion, or other slight causes (^. e. such 
causes as produce palpitation in the healthy state, but 
in a less degree, and of shorter duration) ; or pa- 
roxysms of irregular action, the irregularity being some- 
times in the succession of the pulsations, and some- 
times rather in the mode in which each contraction is 
efi'ected. In all these cases there is more increase of 
the sound, than of the impulse of the heart's action, 
experienced by the ear laid on the chest ; the last of 
these, the irregular contraction of the fibres, is denoted 
chiefly by unnatural sounds attending the pulsations ; 
but these morbid sounds, in such cases, are usually 
slight, and are of short duration. When we are satis- 
fied that such conditions of the heart's action are un- 
connected with organic disease, we usually apply to 
them the term Irritable Heart. 

Such morbidly irregular or excessive action of the 
heart, if unconnected with increased bulk of its muscu- 
lar substance, seldom or never indicates any real in- 
crease of strength. But it is sometimes evidently de- 



OF THE CHRONIC DISEASES OF THE HEART, &C. 539 



pendent on fulness of blood, and increased stimulation 
of the heart ; and farther, it seems a general law, that 
when the heart is feebler than usual, it becomes more 
irritable, its contractions are more easily excited, and 
more easily deranged. Hence both habitual frequency 
of pulse, and likewise fits of palpitation, or irregularity 
of pulse, are often observed under the same circum- 
stances, or in the same persons, as the tendency to syn- 
cope; and are, equally as that tendency, often to be 
ascribed rather to alterations in the state of the ner- 
vous system, than of the heart itself. 

The unusual irritability of heart, indicated by the modi- 
fications of its action above stated, is remarkably observed 
in some persons, previously healthy and perhaps full- 
blooded, when taking little exercise, when enjoying less 
sleep than usual, and when under the influence of men- 
tal anxiety. It is often observed also in persons pre- 
viously healthy, but much weakened, as during con- 
valescence from acute diseases ; and farther, in certain 
chronic diseases, particularly those which are attended 
with habitual uneasy sensations at the stomach. In 
cases of this last kind, inordinate pulsation is often ob- 
served almost exclusively along the abdominal aorta, 
the immediate cause of which is still uncertain. 

Such functional derangement of the heart's action is 
to be distinguished from the eff*ects either of inflamma- 
tion, or of organic disease, by the absence of fever, or 
other marks of carditis ; by the absence (or slight and 
transient degree) of morbid sound ; by the absence of 
any indications of enlargement of the heart ; by the 
presence of nervous symptoms ; and by the afl'ection of 
the heart not being increased, generally gradually di- 
minished by muscular exertion. 



540 OUTLINES OF PATHOLOGY AND PEACTICE. 



Advantage may often be derived, in the earlier stages 
of tliese cases of increased and irregular action of the 
heart, without change of structure, from loss of blood, 
especially when they occur in pretty full habits ; and 
likewise from anodynes, as hydrocyanic acid ; but in 
general, ultimate and permanent relief to them is obtain- 
ed chiefly by the different articles of the tonic regimen, 
by which vascular action is invigorated, and the nervous 
system rendered less liable to sudden and injurious im- 
pressions ; and by medicines of the tonic class, such as 
Steel and Quinine, with such other medicines as the state 
of the stomach and bowels may require. 

III. Painful action of the heart is that affection which, 
in its extreme degree, is described under the name of 
Angina Pectoris, and is marked by acute pain, not only 
in the situation of the heart, but in general extending 
sympathetically to the left shoulder, and down the left 
arm, generally brought on, and always remarkably ag- 
gravated, by any such exertion as may quicken the heart's 
action. This pain occurs, however, in different cases 
with very various degrees of intensity ; and is attended 
with various affections of the movement of the heart, 
generally with increased action at the time when it be- 
gins, but in severe cases, with greatly diminished action 
during its continuance, whence it has had the name of 
Syncope Anginosa. It obviously depends immediately 
on an impression made on the sensitive nerves of the 
heart ; but what circumstances are essential to this im- 
pression is still uncertain. It is not necessarily con- 
nected with any kind of organic disease at the heart, 
but is seldom well marked when no such organic disease 
exists. It is certainly more immediately connected with 

3 



OF THE CHRONIC DISEASES OF THE HEART, &C. 541 



fulness of blood than mere palpitations are, and although 
mitigated by anodynes, and sometimes by stimulants, is 
hardly ever permanently relieved otherwise than by 
evacuations and low diet. 

As both palpitations and painful action of the heart 
must naturally be readily excited, when the tendency 
to them exists, by any cause increasing the quantity of 
blood brought to the heart by the veins in a given time, 
it is easy to understand, that at the moment of transi- 
tion from the state of waking to that of sleep, when the 
circulation on the surface of the body is repressed,* 
these affections of the heart should especially occur, 
hence the " subitanea excitatio a somno" often character- 
istic of diseased heart, though not, as formerly supposed, 
of Hydr other ax. 

It is obvious, that both palpitation and irregular pain- 
ful action of the heart, will more easily be excited when 
there is any obstruction to the free transmission of the 
blood through the heart, than when the motion of the 
blood is free ; and, therefore, that habitually increased 
strength and fulness of pulse, palpitations, irregular 
pulse, and fits of angina pectoris, must be much more 
frequent and dangerous when any disease of the valves 
of the heart, or of the aorta, impeding the transmission, 
or allowing the reflux of blood, exists, than in any other 
cases. And although it is perhaps not so easy to ex- 
plain the fact, it is equally certain, that in those cir- 
cumstances fits of syncope are frequent and dangerous. 

The manner in which such obstruction to the flow 
of blood, through the left side of the heart, especially, 
is produced by inflammation of the Pericardium, and 
more frequently by inflammation of the internal lining 

* See Physiology, p. 406. 



542 



OUTLINES OF PATHOLOGY AND PRACTICE. 



membrane of the heart, was formerly considered ; but 
although many of the lesions of that membrane, and 
of the valves of the heart and aorta, are certainly 
the results of inflammation, — being preceded by the 
causes and symptoms of inflammation, attended by the 
undeniable efi"ects of inflammation, such as the eflusion 
either by lymph or pus, and often resulting from an ob- 
vious metastasis of rheumatic inflammation, — yet there 
are others producing the same ulterior efi'ects, which 
cannot be traced to inflammation, — the disease com- 
mencing gradually, without febrile or inflammatory 
symptoms, and the changes being such as cannot be 
ascribed to a simply inflammatory action, viz. deposi- 
tion of numerous patches, often nearly symmetrically 
arranged, of gTanular, atheromatous, and ultimately 
cartilaginous, or even bony matter, — the latter gene- 
rally deposited in minute irregular specks, at the time 
when the cartilaginous patches are beginning to ulce- 
rate. The whole coats of the arteries in such cases be- 
come thickened, rigid, and inflexible, and the valves at 
the heart become thickened, often shortened, stiff*, and 
unfit for their functions. 

These changes are more various, take place more 
slowly, last longer, and extend farther than the simple 
results of inflammation. They occur, especially in 
persons of bad habit of body, very generally in middle 
or advanced life, and j)robably depend, in part, on a 
morbid condition of the blood; and besides these, there 
are some cases of soft fungous growths, or vegetations, 
on the valves of the heart, which jDroduce similar 
symptoms, but cannot be ascribed to any eff'ect of 
inflammation. These excrescences are often of the 
same nature as the fibrinous concretions found in the 



OF THE CHRONIC DISEASES OF THE HEART, &C. 543 



same cavities, and whicli, from tlieir varying appear- 
ance, and from some indications of organization in 
them, appear to have formed slowly for some time be- 
fore deatli ; and it is, therefore, highly probable, that 
the vegetations are formed of these concretions. 

There are also a few cases of Palpitation, and of fatal 
Syncope, dependent on disease of the muscular parietes 
of the heart, on their being softened, or degenerating 
into a fatty matter; or on the formation of a kind of 
aneurism, after ulceration of the lining membrane, on 
the heart itself (almost always on the left ventricle), 
which may lead to rupture. 

The existence of organic obstructions to the course 
of the blood, is very generally demonstrated, soon after 
they have commenced, and in many instances their 
nature or position is more specifically indicated, by the 
symptoms stated in treating of the effects of inflam- 
mation at the heart ; especially, firsts By the enlarge- 
ment of the heart, and often of the aorta, consequent 
on them, and which is easily ascertained after a time by 
the hand applied to the chest, and especially to the pre- 
cise point of contact of the apex of the heart with the 
parietes ; secondly^ By the increased impulse which the 
heart communicates to the parietes of the chest, when, as 
commonly happens in consequeuce of such obstructions, 
it has got into the state, not only of dilatation, but of 
hypertrophy ; and, thirdly^ By alterations of the natu- 
ral sounds, that attend the heart's actions, — consequent 
on the obstructions which the current of blood en- 
counters, and on the modifications of the muscular 
contractions, which are required to overcome these ob- 
structions. 

While these general characters of organic disease at 
the heart exist, there are many varieties in particular 



544 OUTLINES OF PATHOLOGY AND PRACTICE. 



symptoms, of less urgent importance, but which claim 
attention. The chief of these are the following : — - 

1. In many cases, the pulse at the wi'ist is preterna- 
turally strong, full and regular, or nearly so ; and the 
pulsations of the carotid, and especially of the subcla- 
vian arteries, are felt distinctly to be fuller and stronger 
than natural. In such cases, the aorta is very generally 
enlarged ; and if there be, as is most common, disease 
of the valves, it is of the aortic valves, and of such a 
kind as to admit of reflux of the blood. Of this last 
change we are more certain, if the interval between the 
impulse at the chest and the pulsation at the wrist can 
be observed to be longer than usual. 

2. In others, the pulse at the wrist is small in com- 
parison with that felt at the breast, often very irregular. 
There is no strong action in the carotid or subclavian 
arteries ; and sometimes there are pulsations felt at the 
chest, which do not extend to the wrist. In such cases, 
the aorta is probably little affected ; if there be disease of 
its valves, it is such disease as obstructs the exit of the 
blood from the ventricle : disease of the mitral valve 
may rather be presumed; and, if the last mentioned 
symptom be present, such a state of that- valve is com- 
monly found, as admits of a reflux of blood into the 
auricle. 

3. In some cases, the impulse felt on laying the hand 
or the ear over the heart is very strong, while the sound 
of the heart's action is less than natural. In such. Hy- 
pertrophy of the muscular parietes of the ventricles 
(chiefly the left), is denoted, without dilatation, perhaps 
with diminution of the cavity. 

4. In others, the impulse is weak, while the sound, 
especially the first sound, corresponding to the ventri- 
cular contraction, is unusually loud and sharp. This 



OF THE CHRONIC DISEASES OF THE HEART, &C. 545 



usually denotes Dilatation without hypertrophy. When 
there is both the loud sound and the strong impulse, 
both dilatation and hypertrophy are denoted. 

5. In some cases, the chief impulse and sound are 
perceived near the end of the sternum, and the jugular 
veins appear more turgid, and often pulsate more dis- 
tinctly than usual. In such, enlargement of, and pro- 
bably obstruction on, the right side of the heart are de- 
noted. 

6. In most cases, a preternatural sound, varying con- 
siderably in different cases, but generally characterized 
as the bellows murmur, or the rasping sound, some- 
times a musical sound, is heard to accompany either the 
first and long, or the second short sound of the heart's 
action ; and this generally denotes that some rough or 
irregular obstacle exists, either at the orifice through 
which the blood, in its natural course, is passing at the 

^ time when that sound is produced, or in that through 
V which it has an opportunity, in consequence of the dis- 
P ease, of regurgitating. When this morbid sound is 
heard most distinctly as high as the third rib, the ob- 
struction may be presumed to be at the aortic valves ; 
when as low as the fifth, at the mitral valve. This 
symptom, although very characteristic, is not patho- 
ll gnomonic, because it may undoubtedly be correctly, al- 
m though temporarily, imitated by the motion given to the 
W blood by irregular contractions of the fibres of the heart, 
chiefly in cases of palpitation from affections of the ner- 
vous system, where no organic disease exists. And in 
some cases, especially when the circulation has become 
feeble, no unnatural sound can be observed, although 
there be much valvular disease. 

7. In some cases, the sound on percussion in the situa- 
tion of the heart, is remarkably dull ; which, if taken 



546 OUTLINES OF PATHOLOGY AND PRACTICE. 



along with other indications of organic disease, denotes 
either an effusion into the pericardium, or an unusual 
degree of enlargement and hypertrophy of the heart. 

8. Sometimes a morbid sound cannot be heard over the 
heart, but is distinctly perceptible over the subclavian 
arteries, because dependent on a very diseased state of 
the arch of the aorta and subclavian s, not affecting the 
aortic valves. 

In a few cases we have dyspnoea and painful palpita- 
tion on exertion, and even ultimately fatal syncope, with- 
out either enlargement of the heart, morbid impulse, or 
unnatural sound ; dependent on disease and obstruction 
of the Coronary arteries, implying that the heart cannot 
have its supply of blood duly increased, when increased 
exertion demands it. 

When the unequivocal indications of organic disease 
at the heart exist, the progress of different cases is 
still very various. All such patients are in danger 
of sudden death from slight exertion, or without appa- 
rent cause. The case of hypertrophy, without obvious 
cause, and that of enlargement or hypertrophy from the 
effects of inflammation of the pericardium, are pro- 
bably the only cases in which material amendment of 
the state of the heart may be anticipated, and that 
chiefly from gradual and spontaneous changes. In 
some, all the symptoms may remain stationary for a 
length of time, and not only a comfortable state of ex- 
istence may be enjoyed, but considerable habitual ex- 
ertion may be made ; especially where the symptoms 
belong to the first head above stated ; in others there 
is a rapid increase of the symptoms depending on the 
afiPection of the heart itself ; and in all cases, sooner 
or later, it is to be expected that other complaints, 
consequent on the disordered state of the circulation. 



OF THE CHRONIC DISEASES OF THE HEART, &C. 547 



will supervene, and tlieir indications combine them- 
selves with the symptoms already mentioned. These 
consequences take place more rapidly and more surely 
in young and full-blooded subjects, than in persons 
already old and emaciated. The affection of the heart 
seldom acts as their sole cause ; but as a great and per- 
manent predisposition to them. In the majority of 
cases, some of the exciting causes of disease, and espe- 
cially of inflammatory disease, most generally cold, 
intemperance, or muscular exertion, and some inflam- 
matory disease consequent on them, may be observed 
to aid in producing these effects. When these exciting 
causes are carefully avoided, the fatal effect of the 
affection of the heart may sometimes be averted for a 
long time ; but the longer the organic disease has lasted, 
and the more it has disturbed the circulation, the less 
amount of exciting cause is necessary to produce these 
injurious effects. 

The organic affections of the heart predispose to 
these consecutive diseases, partly, as is supposed, by 
the increased impetus of the blood in the arteries, which 
is given by the heart in the state of hypertrophy ; but, 
certainly chiefly by the obstruction to the flow of blood 
in the great veins, and in the lungs, which is produced 
in the ways above described, and which leads to the 
dilatation or hypertrophy of the heart. 

Of these ulterior effects of such obstruction, the fol- 
lowing are the most important. 

Attacks of Bronchitis are easily excited, and are 
unusually obstinate in such cases j and hence cough, 
expectoration, and habitual dyspnoea, with the sono- 
rous, sibilous, and mucous rales, more or less general 
over the chest, soon supervene in cases of this kind, 
and often attend them from the fii'st. In certain con- 



548 OUTLINES OF PATHOLOGY AND PRACTICE. 



stitutions also, occasional paroxysms of spasmodic 
Asthma (already considered), takes place in this, as 
in all other complaints attended with any permanent 
embarrassment of respiration. In many there are re- 
peated (and alTrays peculiarly dangerous) attacks of 
true Peripneumony. 

2. Attacks of Heemoptysis, and, with or without 
haemoptysis, of Apoplexy of the lungs (of which we 
shall afterwards treat), are also common, particularly 
in cases where the chief obstruction is at the mitral 
valve ; evidently because the auricle has much less power 
than the ventricle, to re-act against any obstruction, and 
maintain the average velocity of the circulation. 

3. Partly in consequence of the increased impetus 
from the left ventricle, in the case of hypertrophy, and 
partly of the obstructed return by the veins of the 
head, dtiring the frequent congestions of the lungs, 
there are frequently symptoms of Plethora Capitis, in 
connexion with organic disease of the heart. In some 
persons there are repeated attacks of Epistaxis, and in 
others, or subsequently in the same, there are strokes 
of Apoplexy or Palsy, or fits of Epilepsy. But for all 
these concomitants of the disease of the heart, a cause 
often appears in an extension of disease of the arteries 
to the interior of the cranium, facilitating their rupture. 

4. The obstructed state of the circulation, in cases 
of diseased heart, and the frequent congestion of blood 
in the lungs, lead very generally (perhaj)s most re- 
markably in young subjects) to stagnation of blood in 
the Liver, — sometimes to occasional turgescence of the 
liver during paroxysms of dyspnoea, and much more 
frequently to enlargement, morbid induration, and de- 
position of one kind or another, both in the liver and 
spleen. 



OF CHEONIC DISEASES OF THE HEART. &C. 549 



5. The same obstructed state of the circulation, espe- 
cially if aided by the exciting causes above mentioned, 
leads generally, sooner or later, to the effusion of serum 
in some part of the capillary circulation, independently 
of inflammation there, {. e, to Dropsical Effusion ; — in 
the cells of the Lungs, in ihe sac af the Pleura or Peri- 
cardium, in the subcutaneous Cellular Substance, and, 
especially after the liver has become affected, in the 
cavity of the Abdomen ; — the symptoms and effects 
of which effusions will be shortly considered after- 
wards. 

From what has been stated, it will readily be un- 
derstood in what manner these organic diseases of the 
heart, besides involving the risk of sudden death by 
Syncope, naturally lead to such changes as threaten 
death, frequently by Asphyxia, and occasionally by 
Coma ; and farther, by the general depressing influence 
of frequent uneasy sensations, and often by the more 
special influence of disease of the liver, so impair the 
actions of digestion and assimilation, as to weaken the 
whole system, and dispose it to suffer from the appli- 
cation, and to sink under the effects, even of slight ex- 
citing causes of disease. 

Such cases of diseased heart, unless when resulting 
from recent and decided inflammation, are in them- 
selves only objects of palliative practice. The coun- 
ter-irritants and deobstruents can hardly be expected to 
be of service, excepting in these incipient cases. The 
palpitations may be moderated by Digitalis, Hydrocy- 
anic acid, or Opium ; more generally by a careful re- 
gim_en, avoiding all excitement of the circulation, and 
all causes of acute disease ; but frequently they be- 
come so violent, as to require the only effectual pallia.- 

PAET III, N n 



550 OUTLINES OF PATHOLOGY AND PRACTICE. 



tive in cases of considerable obstruction, repeated 
Bloodletting, general or local, whicb should be to as 
small an extent as will relieve the urgency of the 
symptoms ; but may often be repeatedly employed with 
good effect, even after dropsy has supervened. By 
these means, and by watching and opposing the first 
threatenings of any of the sequelae above stated, — in- 
flammatory, hsemorrhagic, or dropsical, — many such 
persons may be long kept in tolerable comfort. 

Cases of malformation of the heart, of various kinds, 
of which the general result is a mixture of the blood 
of the right and left sides of the heart, are not uncom- 
mon, and many such persons live till the age of pu- 
berty, although hardly any attain to middle life. They 
are distinguished by permanent lividity of the lips, 
and to a certain degree of the whole surface, coldness, 
and imperfect nutrition of all parts ; are short breathed, | 
and suffer much from dyspnoea on exertion, and the 
name of Cyanosis has been applied to their condition. 
This is a case admitting only of palliative practice, 
especially from a very careful regimen. It has lately 
been distinctly pointed out by Dr Craigie, that in some 
cases the mixture of the venous with arterial blood 
takes place long after birth, in consequence of disease 
and obstruction of the pulmonary artery, and engorge- 
ment of the right side of the heart, stretching the sep- 
tum of the auricles, and pushing asunder the edges of 
the foramen ovale.* 

^ Edinburgh Medical Journal, 1843. 



OF CHEONIC DISEASES OF THE ARTERIES, &C. 551 



Sect. II. — Of Chronic Diseases of the Arteries. 

Various formidable local diseases, besides the affec- 
tions of tbe heart, result in different cases from dis- 
eased conditions of the Arteries. 

1. When ulceration, effected by such a morbid ac- 
tion as has been described above, at any one part of 
an artery, is such as to cause the entrance of blood into 
the cavity thus formed, and its stagnation there, the 
exterior membrane, which resists the ulceration, is 
gradually distended, and the Aneurism of Scarpa, or 
pulsating tumour on an artery, formed by blood which 
has penetrated the two inner coats, and distended the 
outer, is established. In other instances, it must be 
admitted, that aneurismal sacs or pouches are formed 
on arteries, of the mode of formation of which we have 
no such accurate knowledge ; sometimes by the erosion 
of arteries from without, by the pressure of chronic 
abscesses ; and in a few cases, to which the name Dis- 
secting Aneurism has been given, the blood escaping 
by a fissure from the interior of an artery, instead of 
swelling into a pouch at the spot, slits up the coats, 
spreads along the artery, and often escapes through the 
outer coat, by a second fissure, at some distance. 

These aneurisms are found in very various parts of 
the body, chiefly, as may be readily supposed, at flexures 
of the arteries; and as they enlarge, they compress and 
cause absorption of all surrounding textures ; their pul- 
sations are in most parts perceptible to the touch, and 
sometimes, when within the thorax, and not to be 
reached by the finger, may be detected and distinguish- 



552 OUTLINES OF PATHOLOGY AND PRACTICE 



ed from those of the heart by the stethoscope, particu- 
larly by a morbid bndt heard there^ synchronous with 
the first sound of the heart, but not heard over the ven- 
tricle of the heart itself. Their other symptoms are very 
various,- — depending sometimes on the degree of obstruc- 
tion to the circulation which they present, — sometimes 
on the disturbance of the functions of the parts in their 
neighbourhood, as when aneurism of the descending- 
aorta, pressing on the oesophagus, causes dysphagia, or, 
pressing on the lung, causes dyspnoea, and suppresses 
the respiratory murmur at the part ; — often chiefly 
on the nerves, which they stretch or compress, and in 
the extremities of which they excite sympathetic ef- 
fects, e. g. pains in the loins, hips, or thighs, when the 
aneurism is in the abdomeu, in the side of the neck 
or arms, when it is in the thorax, or spasm in the 
larynx, when it presses on the recurrent nerve. These 
effects of aneurisms are sometimes fatal without aify 
rupture of the sac ; but they are more frequently fatal 
by rupture and discharge of blood, very seldom ex- 
ternally, but often into some cavity of the body, — the 
interior of the cranium, the larynx or trachea, the 
stomach or bowels, the cavity of the thorax, or abdo- 
men, or pericardium. The symptoms dependent on 
them are only effectually relieved^ and their fatal ter- 
mination retarded, by the antiphlogistic regimen and 
occasional small bleedings; it has been stated, how- 
ever, that this practice may be carried too far ; and 
may prevent the consolidation and subsequent gradual 
diminution which often take place in aaeurisms. 

2. From the rigid, inela^stic, and brittle state of the 
smaller arteries of the brain, arises very often their easy 
rupture on occasion of sudden determination to the 



OF CHRONIC DISEASES OF THE ARTERIES, &C. 553 



liead, and either apoplexy or palsy; or, even indej^en- 
dently of rupture, such a deranged, probably retarded, 
state of the circulation in tlie brain, as may cause va- 
rious diseases there, to be considered hereafter. 

3. From the same state of the arteries of the extre- 
mities, often perceptible to the touch, and disqualifying 
them for their office in regard to the flow of the blood, 
arises, in many cases, a tendency to Gangrene there 
from slight inflammation, similar to that formerly 
noticed (Part I. p. 303), as resulting in rare cases from 
more acute inflammations of arteries. To such cases 
the term Gangreena Senilis has often been applied, but 
incorrectly, because, although most frequent in ad- 
vanced life, they may occur at almost all ages. In 
cases of this kind, inflammation of this character at 
the extremities of the diseased arteries is often excited 
by very slight causes; and even without it there are 
often violent neuralgic pains, admitting of relief chiefly 
from Opium, not from any operation or incision. But 
we do not understand how it happens, that in many 
other cases, where the arteries are found diseased or 
ossified after death, no such effects had resulted. 

Again, the peculiar thickened and softened condition 
already mentioned, as occasionally observed in the in- 
ner coat of arteries, leads sometimes to sudden rupture 
of the diseased coat, which then becomes coiled up, and 
obstructs the artery, stopping pulsation, and leading 
often rapidly to irremediable gangrene of the limb 
below. 



554 OUTLINES OF PATHOLOGY AND PBACTICE. 



Sect III. — Of Clironic Diseases of the flow of blood 
through^ and exhalations from^ the Capillary Arteries. 

We here treat of Congestions of Blood and Hsemor- 
rliages, and of Dropsy in general ; regarding these as 
the chief diseases which can be distinctly referred to 
variations in the flow of blood, independently of al- 
teration of the products formed from the blood at the 
extremities of the arteries ; and more specifically we 
here consider the ha3morrhage into the lungs^ produc- 
ing apoplexy of the lungs and Haemoptysis, and the 
Hydrothorax ; reserving the other cases of hsemor- 
rhage and serous effusion, until we treat of the diseases 
of the parts where they occur. 

I. There are hardly any chronic local diseases in 
which local determinations and Congestions of blood 
do not occur ; and we are not sufficiently informed of 
the cases in which such irregularity in the distribution 
of the blood may be regarded as the primary or funda- 
mental morbid change. Probably these cases are in 
reality few; but it is important briefly to enumerate 
the principal diseased states, in which morbid deter- 
minations of blood certainly occur, and in a great 
measure determine their extent and intensity, and in- 
jurious results. 

Thus, very various derangements of the functions of 
the Nervous System, headaches, giddiness, transient 
imperfections of sense, or of memory, fits of epilepsy, 
of hysteria or other spasms, even of mania, in those 
predisposed to these diseases, some cases of transient 
paralytic afl'ections, and many of apoplexy, appear to 



OF CHRONIC DISEASES OF THE ARTERIES, &C. 555 



result from simply increased afflux of blood to the 
brain, without rupture of its vessels, disorganization 
of its texture, or even increased effusion of its serous 
fluid. 

So also there are many cases of asthma and of 
catarrh, which may probably depend on merely in- 
creased determination of blood to the mucous mem- 
brane of the air-passages ; but such cases are hardly 
to be distinguished from those either of inflammation 
or of spasm afl'ecting these parts. 

An increased determination of blood to the mucous 
membrane of the stomach, although not followed by 
inflammation there, is probably a frequent cause of 
severe dyspeptic symptoms.* 

An increased flow of blood to secreting organs is 
certainly one condition, and in many cases probably 
the chief condition, essential to the production of those 
diseases which consist in simple increase of their se- 
cretions, such as cholera, or many cases of diarrhoea 
and of leucorrhoea. 

Even independently of attacks of haemorrhage, there 
is evidence of increased flow of blood to the uterus, in 
many cases of uterine pains ; and of a similarly in- 
creased flow to various other parts in connexion with 
nervous pains, i. e. pains which are unconnected with 
indications of inflammation. 

An increased flow of blood to, or stagnation of blood 
in, the serous membranes, or the cellular membrane of 
the body in general, or of the lungs, — whether it be de- 
pendent on obstruction to the circulation in the great 

* See Parry's Elements of Pathology and Therapeutics, sect. 
484. 



556 OUT^LINES OF PATHOLOGY AND PRACTICE. 



veins, as in cases of diseased heart or liver, or on sup- 
pression of excretion by the skin and kidneys, as in 
cases of dropsy after scarlatina, or be connected with 
the altered state of the blood attending disease of the 
kidneys, — is certainly a condition essential to the oc- 
currence of dropsical effusion in those parts. 

As true inflammation of cellular, serous, or mucous 
membrane is always attended with increase of the 
quantity of fluids thrown out there, it is obvious that 
effusions dependent on simple congestion of blood, and 
those dependent on inflammation, must often closely 
approximate ; and the only essential distinction be- 
tween them lies in the peculiar alterations of the pro- 
ducts eft\ised in those parts, which are effected by in- 
flammation, and which have been already described. 

All the diseased states now mentioned, proceed fre- 
quently from the same exciting causes as inflamma- 
tion, and especially from the suppression of other 
evacuations, — more remarkably of the menstrual dis- 
charge than of any other. 

In many instances of the kinds now stated, the 
symptoms are the same, and the whole history of the 
disease, up to a certain period, is the same, as in other 
cases, where the increased determination of blood is 
afterwards unequivocally shewn by haemorrhage ; e. g, 
a fit of apoplexy, in a plethoric person, after a full 
meal, and either mental agitation or intoxication, aU 
though preceded and attended with flushing of face, 
and heat of the head, may be fatal w^ithout any effu- 
sion being discoverable in the head ; but after many 
cases of fatal apoplexy, of which the history is si- 
milar, we find effusions of blood ; and we cannot 
doubt that these latter cases illustrate the essential 



OF CHRONIC DISEASES OF THE ARTERIES, &C. 557 



nature of the diseased action which took place in the 
former. 

So also, urgent dyspeptic symptoms, following sup- 
pression of the menses, have often been succeeded, and 
immediately relieved, by vomiting of blood ; and this 
fact evidently so far illustrates the nature of the severe 
affections of the stomach which often succeed the sup- 
pression of that discharge, when there is no haemor- 
rhage. And the nature of many cases of diarrhoea is 
illustrated by what is seen in a few unusually violent 
cases of that kind, which are attended by severe 
hsemorrhao'e, even when there is no inflp.mmation or 
ulceration, and no obstruction to the flow of the venous 
blood through the liver. 

Again, the nature of such chronic diseases, involving 
determinations of blood, is very often illustrated by 
their ready transition, in the same patient, into hse- 
morrhagic or inflammatory diseases. Thus we know 
that various combinations or successions of symptoms 
of afl'ection of the nervous system, the cause of which 
may be thought doubtful if they stand alone, are often 
followed by regular apo]3lectic or paralytic attacks 
dependent on hsemorrhage in the brain ; and that 
cases of simple diarrhoea are easily convertible, by errors 
of regimen, which in other circumstances would be in- 
nocent, into strictly inflammatory diseases. 

Farther, the dependence of many cases of these 
diseases on the cause here assigned, is farther con- 
firmed by a very sufficient experience of the juvantia 
* and Icedentia^ in at least a large proportion of cases of 
the kind, especially in their earlier stages \ although 
experience also teaches that morbid actions which com- 
mence with increased local determinations of blood, and 



558 OUTLINES OF PATHOLOGY AND PRACTICE. 



even with general excitement of the circulation, and 
whicli threaten or even go on to dangerous heemor- 
rhage, often subsequently continue for a long time, 
without any indications of increased flow of blood, 
and when remedies are chiefly demanded by the ge- 
neral weakness of the circulation which subsequently 
ensues. 

There are probably cases of afl'ection of the lungs, 
and certainly cases of affection of the brain, where the 
fatal event is produced by the injury of these parts 
consequent on mere congestion of blood, without far- 
ther change ; and there are many cases of very various 
diseases, in which congestions of blood in these organs 
are part of the cause of the fatal event. It is therefore 
of great importance to study the indications of mere 
Congestion of Blood, as well as the effects of Haemor- 
rhages, as they appear on dissection. 

It may, however, be stated generally, that the indi- 
cations of local congestions of blood, observed after 
death, when no farther consequence has occurred, are 
very liable to fallacies, and are not much to be trusted 
as proofs of the nature of the preceding disease, unless 
the nature of the symptoms, or other circumstances in 
the condition of the patient, confirm the conclusion 
which they suggest. 

These fallacies result chiefly from what is known of 
the unequal and irregular distributions of blood that 
may take place at the moment of death, or within a 
very short time before it, even in cases where there 
had previously been little or no unusual determination 
of blood. 

At the moment of death, or soon after it, conges- 
tions of blood in various parts and textures (at least in 



OF CHRONIC DISEASES OF THE ARTEBIES, &C, 559 



the skill, most of tlie vascular parts, mucous mem- 
branes, and the parenchyma of some of the viscera), 
frequently occur; which are not referable to any 
known cause, but may be followed by transudation of 
serum after death, and present appearances very simi- 
lar to those of inflammation in its first stage. 

A congestion of blood, with some serous effusion, 
and even extravasation of entire blood, is certainly 
often determined also by gravitation, acting before 
death, but at the time when the circulation is very 
much enfeebled, in those parts of the body which 
then lie lowest.* This takes place especially, if any 
additional cause for slow motion of the blood at the 
same time exists in these parts ; as in the lungs, when 
there is any impediment to the free arterialization 
of the blood, or in the abdominal viscera, when the 
flow of venous blood is obstructed either in the liver or 
at the lungs or heart. A similar state of congestion 
and serous effusion sometimes occurs in the lower ex- 
tremities from old age or extreme debility ; and in 
any part of the body, if the veins leading from it are 
narrowed or compressed by tumor s.f 

Such congestions and effusions are of course most 
apt to take place in cases when the blood is in full 
quantity, and has less tendency to coagulation than 
usual, and therefore such fallacious appearances are 
seen most frequently after different kinds of violent 
death, or after contagious febrile diseases of short 
duration. 

* Hence the Peripneumonie des agonisans of Laennec, and the 
Engouement de Position of Andral. 

t See Andral, Precis d"*Anat. Pathol, t. i. 



560 OUTLINES OF PATHOLOGY AND PRACTICE. 



But when the same appearances are found in parts 
of tlie body wliere gravitation would not determine 
them, — when thej are found under the circumstances 
stated above, as favouring local congestions of blood, — 
and when they correspond to symptoms observed dur- 
ing life, of embarrassment of the functions of the parts 
where they are formed, especially of haemorrhage, and 
when they are found after death associated with such 
lesions as result from haemorrhages, there can be no 
difficulty about regarding them as the effects and indi- 
cations of morbid determinations of blood. 

The only practical inference which we state at pre- 
sent from the facts here noticed is, that, in all the 
diseased states above enumerated, especially if of re- 
cent occurrence, and attended with a vigorous state of 
the circulation, depletion, and the antiphlogistic regi- 
men, although seldom requiring to be carried so far 
as in inflammations, will often form an important part 
of the most useful plan of treatment. 

II. Haemorrhage frequently takes place from the mu- 
cous membranes of the nose, fauces, bronchiae, stomach 
or bowels, and still more frequently of the uterus ; in 
some cases in such quantity as to be dangerous or fatal, 
by reason of the debility produced by the loss of 
blood, or, in the case of its occurring in any of the 
air-passages, by reason of the obstruction to respiration 
thence produced. When taking place from the inner 
surface of the uterus, at the moment of the separation 
of the placenta, it has often been fatal in persons pre- 
viously quite healthy ; but in the other j^arts men- 
tioned it is seldom immediately dangerous, unless con- 
nected either with the morbid state of the blood, or 



OF CHRONIC DISEASES OF THE ARTERIES, &C. 561 

with some of the obstructions to the free course of the 
blood, formerly mentioned. In all these parts, it often 
appears, on minute investigation, that no rupture of 
vessels on the surface whence the blood came can be 
detected, and, in a few instances, from the surface of 
the skin, and in many, from the mucous membrane of 
the uterus, blood has been seen to exude in minute 
drops, without any breach of texture. 

Hence haemorrhage is usually regarded at present as 
simply a diseased state of exhalation ; perhaps it has 
been of late too exclusively so considered, for certainly 
the grea^ter number of fatal ha3morrhages in any of the 
shut cavities of the body, and some of those which 
take place from mucous membranes, are the result of 
rupture or erosion of bloodvessels. 

Effusion of blood into the substance of the lungs 
is not so common as that into the brain, to be after- 
wards considered ; the effusion, in most cases of 
haemoptysis, being either into the bronchiae, or into 
ulcerated cavities ; but it takes place occasionally, and 
has been accurately described under the title of Apo- 
plexy of the Lungs ; and the history of the organic 
lesion thus effected is important. 

This haemorrhage takes place occasionally when 
there is no organic disease within the chest ; pretty 
frequently when there is other disease of the lungs, 
limiting and obstructing the circulation ; most fre- 
quently when there is disease of the valves on the 
left side of the heart, and consequent impediment to 
the movement of the blood there. The bloody effusion 
into the lungs is most generally attended with haemop- 
tysis, but the amount of that discharge bears no pro- 
portion to the extent of the effusion, and sometimes, 
even in fatal cases, it is altogether awanting. 



562 OUTLINES OF PATHOLOGY AND PRACTICE. 



Besides the haemoptysis, the effusion of blood into 
the air-cells must naturally produce sudden dyspnoea, 
and disorder of the heart's action, and more or less of 
local inflammation ; and when it is in any considerable 
quantity at one spot, it must obscure or suppress the 
natural respiratory murmur, and even make that part 
of the chest dull on percussion ; but these last indica- 
tions are equally given by various other lesions, for- 
merly mentioned. When, however, they take place 
rapidly, with sudden dyspnoea, with heemoptysis, how- 
ever slight, and especially in a case where there are 
indications of diseased heart, it may be suspected that 
they proceed from this cause ; and in such cases, the 
affection is sometimes rapidly fatal. 

The appearance, in the dead body, of the lesion of 
the substance of the lung thus caused, is just that of 
a coagulum of venous blood filling up a part of the 
cellular texture. The colour is darker and more uni- 
form, the texture is firmer, and the edge more cir- 
cumscribed, than in the case of effusions from inflam- 
mation. 

Blood thus effused' into the substance of the lung, 
does not appear so rapidly to excite inflammation 
around it, as in the brain ; and it is not, therefore, 
found afterwards to be surrounded with any cyst ; but 
in the lungs, as in the brain, and as in the cellular sub- 
stance after bruises, such simple effusions of blood, in 
the perfectly healthy state, appear to be easily ab- 
sorbed ; and judging both from the gradual improve- 
ment of the general symptoms after many cases of 
haemoptysis, with much dyspnoea (unconnected with 
phthisis), and from the gradual abatement of the indi- 



OF CHRONIC DISEASES OF THE ARTERIES, &C. 563 



cations of effusion given in such, cases by auscultation 
and percussion,* we may presume, tliat large coagula 
of blood may be absorbed from the cellular texture of 
the lungs, and the functions of the part gradually re- 
stored ; although the complex and necessarily danger- 
ous nature of most of the cases, where this accident 
happens, prevents our having many examples of this 
kind. 

In all situations, where effusions of blood occur 
from disease, we have reason to believe, that the blood 
effused in a few cases becomes an organized mass, and 
then is gradually converted into different kinds of 
tumor. This we gather from careful examination of 
some instances of the kind, where successive effusions 
have taken place, and are found at the time of death 
in different stages of their progress. f But as many 
facts inform us, that blood effused in the perfectly 
healthy state is readily absorbed, it is obvious that 
there must be some constitutional peculiarity in the 
cases, where such transformation of effused blood takes 
place j and where such peculiarity exists, we have 
good reason to believe, that mere congestions of blood 
lead to the formation of adventitious textures (very 
little liable to absorption) without any haemorrhage. 

It may be judged from what has been stated, that 
hsemorrhages may occur in very various circumstances, 
and with great variety of concomitant general symp- 
toms ; and accordingly, the practice to be employed 
in them is various. 

* See Laennec, t. i. p. 383. 

•f See e.g. Andral, Precis, &c. t. ii. p. 589 and 764, 



564 



OUTLINES OF PATHOLOGY AND PRACTICE. 



The most powerful remedy in checking heemorrhage 
is general Bloodletting; and in many cases, where the 
disease is attended with febrile symptoms, either con- 
nected with the sudden local determination of blood, 
or with incipient inflammation, excited by the effused 
blood, large and repeated bleedings are obviously de- 
manded, and well borne. In such cases also the anti- 
phlogistic regimen in all its parts, absolute rest, re- 
peated purging, the local application of cold, if the 
part is near the surface, and sedative medicines, parti- 
cularly nauseating doses of antimonials, properly pre- 
cede the use even of astringents. If the part is ac- 
tually within reach, the saturated solution of alum, 
and the lunar caustic, are the most powerful appli- 
cations. 

But when the circulation becomes weakened, as the 
disease advances, or if it is much weakened from the 
first, internal astringents are more important. The 
Acetate of Lead in full doses, pretty frequently repeat- 
ed, has appeared to answer well in many cases ; the Sul- 
phate of Alumina in others ; the Sulphuric Acid, and 
more especially the Gallic Acid, in others. The Sul- 
phuric Acid or Sulphates must not be combined with 
the lead, on account of their chemical action on it. 
The Oil of Turpentine has been thought useful ; but, in 
general, vegetable astringents are less approved in these 
cases, and Opium seems chiefly useful when the hae- 
morrhage is in the intestines, and attended with diar- 
rhoea. 

And in some cases, particularly of haemorrhage from 
the stomach or bowels, or uterus, the state of the cir- 
culation becomes such as to demand the full use of 
alkohol and other stimulants, even while the heemor- 

6 



OF CIirtONIC DISEASES OF THE ARTERIES, &C. 565 

rliage continues to recur. Of course, the proper ap- 
plication of these different remedies may often require 
much discrimination, and it is particularly necessary 
to remember that there is in many persons the irritable 
condition of the Heart, called " Reaction after loss of 
Blood," attended often with throbbing at the temples, 
sometimes with delirium, which may give a fallacious 
impression of the heart's strength, even when there are 
all other indications of extreme weakness, and when 
laxatives, opiates, and stimulants may be found the 
most effectual remedies. 

The subsequent treatment must depend on the other 
diseased states with which the haemorrhage is compli- 
cated, e. g. previous disease of the heart,, or lungs, or 
amenorrhoea, or purpura and the heemorrhagic dia- 
thesis ; in all cases, such exercise as particularly excites 
the part affected, must be long and carefully avoided ; 
and in the case of haemoptysis, the patient must al- 
ways be treated, for a long time after, as one who is 
threatened Avith one form or other of ulceration of the 
lungs. 

III. Dropsical Effusion, i, e, increased and somewhat 
altered Exhalation into the shut cavities, or cellular 
membrane (without any of the effusions characteristic 
of inflammation), is the most essential part of the mor- 
bid change in many cases of disease, and often the imme- 
diate cause of death by Coma or Asphyxia, and there- 
fore is properly made a subject of separate study. It 
is most generally, however, like haemorrhage, consecu- 
tive on other diseased states, often part of very com- 
plex diseases ; and after what has been said of inflam- 
mation, and of congestions of blood, as causes of se- 
PART III. o o 



566 



OUTLINES OF PATHOLOGY AND PRACTICE. 



rous effusions, and likewise of obstructions to tlie free 
movement of blood, especially in the veins, as a great 
predisposing cause botb of inflammation and conges- 
tion, we need not dwell at any length on tlie pathology 
of Dropsy. 

We mentioned formerly two cases in which merely 
serous effusion, consequent on inflammatory action, 
without any obstruction to the return of the venous 
blood, may be fatal, viz. the common case of rapid 
effusion of serum into the ventricles of the brain; 
and the rare case of pneumonia, affecting both lungs 
at once, and fatal by serous effusion into the cells of 
the lungs, before any but that first effect of inflamma- 
tion has taken place. 

There are also cases of fatal Coma in adults, some 
very rapid, others slow in their progress, where nothing 
but effused serum is found after death, and no dis- 
tinct marks of inflammation have preceded the coma, 
and which have the name of Serous Apoplexy ; in 
such cases, likewise, the precise resemblance of the 
symptoms to many of those in cases where haemorrhage 
is ascertained to have taken place, and the experience 
of the juvantia and Isedentia, entitle us to say that 
the effusion is generally to be ascribed to increased de- 
termination and congestion of blood, although no ob- 
stacle to the return of the venous blood may exist. 

The Hydrocele, or dropsy of the tunica vaginalis 
testis, is another case, often referable^ in the first in- 
stance, to an inflammatory action, — as when it is ex- ! 
cited by a blow, — and although naturally favoured by f 
the position of the part, not distinctly referable to ob- | 
struction of the venous circulation. | 

In other cases, dropsical effusions are apt to go on to i 



OF CHKONIC DISEASES OF THE AllTEEIES, &C. 567 



a greater extent than in these, and perhaps in all others 
it is an essential part of the disease that some impedi- 
ment exists, if not to the flow of blood in the veins, at 
least to its natural movement in some part of the sys- 
tem, which retards the capillary circulation on some 
considerable surface, and favours the escape of more 
than usual of the serous part of the blood. 

In general, in dropsical cases, the vital actions in the 
vessels which yield the effusion have not undergone any 
change in kind^ as they uniformly have in cases of in- 
flammation j but the natural action of Exhalation from 
these vessels predominates over that of Absorption ; gene- 
rally on account of some impediment to the return of 
venous blood from them, situated at some distance from 
themselves, but causing congestion and retarded flow in 
them, and facilitating transudation from them. 

There are some cases, even of general dropsy, where 
no such impediment to the circulation can be detected, 
but such cases are in general slight and easily removed, 
unless they occur towards the close of a long continued 
disease, which is dangerous in itself. The truly impor- 
tant distinction among dropsies is according to the 
nature and seat of the local disease, obstructing or im- 
peding the circulation, with which they are connected ; 
but it is of course necessary likewise to ascertain, as far 
as possible, in every case, what cavities are occupied by 
the effusion. 

Anasarcous or oedematous swellings, dependent on ef- 
fusion into the subcutaneous cellular membrane, are 
easily known by their soft feel, without discoloration, 
and b)y pitting on pressure ; and the Ascites, or effusion 
into the cavity of the abdomen, by the sense of fluctua- 
tion felt with one hand when the abdomen is gently 



068 OUTLINES OT PATHOLOGY AND PRACTICE. 



struck by the other, particularly if this is most distinct 
in the part of the abdomen which is lowest in the posi- 
^aon of the patient. 

The effusion into the cavity of the Chest is not so 
easily discriminated, especially as it is very often only a 
part of the cause of the dyspnoea, and other general 
symptoms, which are present;, and when it occupies 
both sides of the chest, it may be a cause of consider- 
able dyspnoea, without going to such an extent in either 
as to be distinctly ascertained by examination. But in 
mxany cases, the dull sound on percussion, and obscured, 
or even suppressed respiratory murmur, in whatever 
part of the chest is lowest at the time of examination, 
and especially the disappearance of these symptoms in 
that part, when it is made highest^ unequivocally denote 
the disease. 

The dropsy of the Pericardium, when unattended with 
any strictly inflammatory effusion, seldom exists without 
dropsy in other parts of the chest, and other disease 
within the chest ; its diagnosis is uncertain, but when 
considerable it causes a dull sound on percussion j usual- 
ly makes the heart's action feeble and irregular, with 
variable and perhaps undulating impulse ; and the re- 
cumbent and especially the supine position insupport- 
able. 

In many cases dropsical effusion, though without in- 
flammatory symptoms, takes place into the cells of the 
Lungs, more than into any other part within the chest. 
In such the sound on percussion is hardly sensibly al- 
tered ; but the respiratory murmur at the part that lies 
lowest is obscured, a.nd sometimes the crepitant or sub- 
crepitant rale may be perceived ; but as this case is 
generally complicated, at least with chronic bronchitis, 



OF CHBONIC DISEASES OF THE ARTERIES, &C. 569 



causing the sonorous and mucous rale, the diagnosis is 
generally difficult. 

The increase of dyspnoea on lying down, although often 
a striking, is neither a uniform nor characteristic, symp- 
tom of any serous effusion within the chest ; and the 
starting from sleep is certainly not an effect of this ef- 
fusion, depending generally, when it is ohserved, oii 
concomitant disease of the heart. But the presence of 
anasarca, and of scanty urine, especially if these can be 
ascertained to have been contemporaneous with the at- 
tack of dyspnoea, always give great reason to suspect 
that effusion exists ; there being few cases of any con- 
siderable dropsy either of the thorax or a^bdomen witli- 
out these symptoms. 

The internal parts, with disease of which dropsy is 
most naturally connected, with the symptoms of which, 
therefore, its indications are most frequently combined, 
are the Heart, the Lungs, the Liver, and the Kidneys. 
The effect of almost all organic diseases, or of inflam- 
matory effusions, at the heart, at the lungs, or at the 
liver, in retarding the flow of blood in the great veins, 
either the venee cavse, or the vena portae, requires no 
illustration. When the kidneys are diseased, in the 
way formerly described, as the most common, although 
no great veins be affected, the natural outlet of part of 
the serum of the blood is more or less obstructed ; and 
in such cases, as the albumen of the serum is partly 
drained off, and diminished in proportion to the serosity, 
it is likely that the latter is habitually in a state more 
prone to effusion, just as the whole blood is when de- 
prived of a part of its fibrin, in the experiments of Ma- 
gendie. Accordingly it has been found by Andral 
that in sheep, dropsy attends diseases of the liver, only 



570 OUTLINES OF PATHOLOGY AND PRACTICE. 



when tlie serum of tlie blood is deficient in albumen. 
Chronic diseases of the peritoneum and of the mesen- 
teric glands, are likewise frequently attended with 
dropsy, probably by reason of pressure on some of the 
mesenteric veins. 

The following appear the most important principles 
to be kept in mind, regarding the connection of dropsy 
with the diseases of these parts. 

1. It is not a uniform, and therefore not a necessary 
consequence, of any disease that we can specify in any 
one of these parts ; and the chronic diseases of them, on 
which it so frequently supervenes, may be regarded 
simply as great and ipermsa-ient predisponent causes of it. 
When that predisposition exists from chronic disease 
of one of these parts, an acute disease, although slight, 
of another of them, or even a general disturbance of 
the circulation, is often the exciting cause of the first 
accession, or of the subsequent returns of dropsical effu- 
sion ; and the greater the amount of the permanent 
predisposition, and the more frequently the dropsical 
effusion has recurred, the less action of any exciting 
cause is necessary to reproduce it. There are, how- 
ever, cases of peculiar tendency to dropsical effusion, 
the cause of which is quite obscure. 

2. Inflammation of the heart, of the lungs, or of the 
kidneys, appears in some cases to excite dropsical efiu- 
sion, when no other disease of internal organs exists. 
This we conclude from the dropsy, whether general or 
partial, supervening almost immediately on the usual 
symptoms of inflammation of these parts ; — or, in the 
case of the kidneys, from its being attended with the al- 
buminous urine, of low specific gravity, and taking place 
suddenly, generally from exposure to cold, and with fe- 



OF CHRONIC DISEASES OF THE ARTERIES, &C. 571 



brile symptoms. Siicli cases have tlie name of Acute 
or Inflammatory Dropsy. But in most cases of dropsy 
supervening so rapidly on inflammation of any one of 
these organs, it will probably appear, on careful exami- 
nation, that another of them is at least slightly inflamed 
also; e.g. that some degree of pneumonia or bronchitis 
attends either the acute dropsy with coagulable urine, 
or that which is apparently owing merely to inflamma- 
tion at the heart. The acute dropsy after scarlatina is 
generally attended with coagulable urine, and may there- 
fore be supposed to depend on subacute inflammation of 
the kidneys, coinciding perhaps with the obstructed state 
of the excretion of the skin. But in severe cases of this 
kind, inflammation within the thorax is very generally 
present likewise. 

3. In like manner, when dropsy supervenes on chro- 
nic and organic disease only, of the organs above men- 
tioned, it is most commonly owing to a complication of 
such disease in more organs than one. 

4. When the permanent predisposition, resulting 
from organic disease of one or more of these organs, 
exists, it is important to be aware of the nature of the 
supervening diseases, from which attacks of dropsy are 
most to be apprehended. 

a. Most of the attacks, in this description of patients, 
which take place suddenly, especially if the dropsy is 
general, appear to depend on an inflammation, often 
of no great intensity, in the lungs or bronchise (which 
will necessarily be attended with some acceleration of 
the pulse, and at the same time with some impediment 
to the flow of blood through the lungs) ; supervening 
either on disease in the left side of the heart, — or on 
permanent organic disease {e.g. partial condensation 



572 



OUTLINES OF PATHOLOGY AND PRACTICE. 



from previous inflammation) of tlie lungs themselves, or 
on an obstructed state of tlie liver or kidneys. 

5. There are other cases in which pretty acute, but 
more partial, dropsy supervenes on these chronic and 
organic diseases, and where its immediate cause appears 
to be a subacute inflammation of the membrane where 
the effusion takes place, generally the pleura or peri- 
toneum ; and in some such cases, on dissection, a few 
flakes of adhesive lymph are found mixed with the 
serous effusion ; i, e. the affection of the serous membrane 
evidently commences as inflammation, but an unusual 
amount and duration of serous effusion, consequent on 
that inflammation, is determined by the existing organic 
disease which retards the venous circulation. 

c. When dropsy supervenes more slowly on organic 
disease of the heart, it may often be ascribed, in part, 
to the gradual accession of chronic bronchitis, to which 
it was formerly stated, that any obstruction on the left 
side of the heart gives a great predisposition. In this 
case, the effusion into the cells of the lungs is fully as 
common as that into the cavity of the chest. 

cL When dropsy, especially if ascites, slowly super- 
venes on chronic disease of the lungs {e. g. on old asthma 
and emphysema), the reason generally is, that the liver 
has become hardened and obstructed. 

Here it should be observed, that as hydrothorax, or 
general dropsy, from disease within the chest, is more 
frequently, in part, dependent on a temporary and re- 
mediable cause {e. g. bronchitis) than ascites from dis- 
ease of the liver, so it is more frequently seen to abate 
under remedies. 

e. Dropsy with diseased kidney is probably more 
variable than that dependent on any other cause — often 



OF CHRONIC DISEASES OF THE ARTERIES, &C. 573 



abating entirely, witliout any improvement of otlier 
symptoms. And there is this peculiarity attending it, 
tliat the bulk of the urine passed in the day is some- 
times fully as great as natural ; and in some instances 
is raised by medicines considerably above what is na- 
tural, for some time together, without diminution of 
the dropsy ; whereas in other cases of dropsy, a full 
flow of urine, though often a temporary, is a certain 
cause of absorption of the effused fluid. 

4. As a certain degree of retardation of the motion 
of the blood seems essential to dropsical effusion, it is 
easy to understand, that while on the one hand it is 
favoured by such a degree of fulness of blood, as in- 
creases the effect of any mechanical impediment to the 
circulation, — and is more apt to supervene, therefore, on 
a given amount of obstruction at the heart in a young 
and strong, than in an old and feeble subject, — it must 
also, on the other hand, be favoured by such a state of 
weakness as hinders the blood in the capillaries from 
receiving their due impulse from the action of the heart ; 
and therefore may often gradually supervene in the 
later stages of diseases where any organic obstruction 
exists, although absent in the earlier stages ; and may 
in some such cases be apparently promoted by evacua- 
tions of blood. The effusion into the cells of the lungs, 
in particular, is apt to occur, in a greater or less de- 
gree, in circumstances of extreme debility, from w^hat- 
ever cause that may arise. 

Dropsical effusion is always injurious to the strength 
of the circulation in the capillaries in its immediate 
neighbourhood, which must necessarily be impeded by 
the pressure of the effused fluid ; as is distinctly shewn 
by the coldness of dropsical limbs, and still more by 



574 OUTLINES OF PATHOLOGY AND PRACTICE. 



tlieir peculiar tendency to gangrene wlien inflamed. In 
this waj sucli effusion in the abdomen must necessarily 
impede the functions going on there, and so co-operate 
towards the fatal event of cases where it occurs. In 
the thorax it is frequently the cause, or great part of 
the cause, of death by Asphyxia. And when much 
dropsy, especially within the chest, exists, even inde- 
pendently of disease of the heart, sudden death is not 
uncommon. Lastly, in the course of dropsical diseases, 
effusion not unfrequently takes place in the ventricles 
of the brain, and causes fatal Coma ; and this some- 
times unexpectedly, without increase of the other drop- 
sical effusions. Of course, the prognosis in dropsical 
cases is always uncertain, and very generally ultimately 
unfavourable. 

There are many cases of partial dropsy, as, e. g. of 
the lower limbs, evidently explained by compression, 
or some mode of obstruction, of the larger veins lead- 
ing from the part, as by enlarged lymphatic glands. 
The most remarkable case of the kind is the Phleg- 
masia dolens, the connection of which with Phlebitis 
was formerly considered. But in this case the serum 
effused into the cellular texture of the limb is some- 
what albuminous, or nearly of gelatinous consistence, 
so that the swelling has a degree of elasticity. A some- 
what similar condition of the effused fluid is seen in 
some cases of anasarcous effusion from more common 
causes. 

The effusion of firm matter into the cellular mem- 
brane of new-born infants, which is occasionally seen, 
and even prevails epidemically at times, and has the 
name of Skinbound, has been likewise described as a 
kind of oedema ; but appears to be rather a variety of 



OF CHRONIC DISEASES OF THE AETERIES, &C. 575 

erysipelatous or diffuse inflammation of tlie cellular 
membrane. 

A great part of the remedies to be used in cases of 
dropsy must be directed by the inflammatory or organic 
diseases, witb whicli the eff'usion is connected, or of which 
it is a consequence ; and particularly the use of blood- 
letting, and of mercury or other deobstruents, which are 
often the most important remedies in such cases, must 
be guided by the symptoms of those diseases ; the only 
general rule being, that when these symptoms appear 
manifestly to demand those remedies (especially the first), 
they are not to be regarded as coiitra-indicated by the 
presence of dropsy, although that concomitant of the 
disease, especially if in the chest or pericardium, is a 
reason for caution and moderation in the use of blood- 
letting. 

The dropsical eftusion itself is chiefly an object of 
practice when any inflammatory symptoms are declining, 
or have abated, and the following are the most import- 
ant general rules that can be laid dovvn in regard to it : — 

1. It may be, in most cases, more promptly and surely 
carried off by the action of strong or hydragogue Ca- 
thartics than by any other means, e.g. by Elaterium in 
small but repeated doses, Croton Oil, Gamboge, or Jalap, 
Scammony, &c., with or without the Bi-tartrate of 
Potass, or the latter alone. The weakness of some pa- 
tients, and the tendency to nausea and vomiting in others, 
are the chief objections to this practice ; under which, 
however, when certain intervals of rest are allowed, we 
not unfrequently see, not only the effusion disappear, 
but the strength gradually improve. In some persons 
we see these medicines taken singly (especially the two 
first), act remarkably well ; but it has been more gene- 



576 OUTLINES OF PATHOLOGY AND PRACTICE. 

rally thought that a combination of several, with one 
another and with Calomel, acts more mildly and effectu- 
ally. It is in all cases essential, for this object, that 
full watery evacuation be procured. 

2. The Diuretics, when they act fully, causing a de- 
cided excess of the urine over the fluid ingesta, never 
fail for the time to remove the dropsy, except in some 
very unusual cases of disease of the kidney ; and their 
action has no debilitating effect ; but then it is very un- 
certain, especially in the more advanced complex cases 
of organic disease, and many of the diuretics cannot be 
continued on account of th^ir sickening effect. The fol- 
lowing rules as to their use seem to be justified by ex- 
perience : — 

They generally act best when several are combined, 
and the combination which is perhaps most frequently 
successful, is that of vegetable diuretics, particularly 
Squill and Digitalis, with Mercury. This is especially 
useful when the urine is acid, high coloured, and with a 
copious reddish sediment. 

In other cases of the same description, a combination 
of the Saline Diuretics, Acetate, Carbonate, or Hydriodate 
of Potass, with the vegetable diuretics, and likewise with 
some of the bitters, infusion of Quassia or of Pyrola, or 
decoction of Broom and Juniper, are more effectual. 

In others the saline diuretics alone, particularly a 
mixture of several, as of Bi-tartrate of Potass, Nitrate 
of Potass, and Carbonate of Potass or Soda, or of the 
Bi-tartrate with Sub-Borate of Soda, act satisfactorily. 

When the urine is pale, of low specific gravity, and 
albuminous, implying the renal disease formerly de- 
scribed, the more acrid diuretics seem to be contra-indi- 
cated, particularly in the early stage ; and Mercury is 



OF CHRONIC DISEASES OF THE ARTERIES, &C. 577 



peculiarly apt to act violently ; but tlie Bi-tartrate of 
Potass with Digitalis, and even small doses of Mercury, 
cautiously given, have often acted remarkably well. 
. "When there is much weakness, and no indication of 
active inflammation, many of the symptoms will be re- 
lieved, and the effect of the diuretics promoted, by fre- 
quent small doses of stimuli, particularly wine, gin, and 
nitrous ether. 

On the other hand, in a plethoric state of the body, 
and when the pulse is full and firm, although there be 
no local inflammatory symptoms, bloodletting or purging, 
or both, previous to the diuretics, obviously aid their 
action. 

The absorption of dropsical effusion seems to be al- 
ways promoted by free cutaneous transpiration, — by 
exercise when the strength of the patient will admit of 
it, — ^by summer weather, — by warm clothing, and in 
some instances by the warm bath and diaphoretic reme- 
dies. The latter have been naturally and particularly 
recommended in cases of Renal Dropsy, but are certainly 
often employed, in such cases, without obvious effect. 

When the distension of the skin by serous effusion is 
great, and inflammation with ulceration or sloughing 
likely to ensue, these consequences may sometimes be 
averted, and the removal of the effusion obtained by 
small punctures and by the aid of bandages; but the 
punctures should be minute and not below the knee, and 
the skin should be protected against the serum that 
exudes, by oiled silk coverings, lest these punctures lead 
to inflammation and sloughing. 

The removal of the dropsical effusion seldom implies 
the disappearance of the disease from which it originates ; 



578 OUTLINP^S OF PATHOLOGY AND PEACTICE. 

but there are a few cases, in which its cause is obscure, 
and the effusion, once removed, is not reproduced ; and 
many where the dangers, obviously the most imminent, 
are obviated by the absorption of the effusion ; and in 
which the more permanent disease may subsequently 
last long without recurrence of the dropsy, or other very 
serious consequence. 



C 579 ) 



CHAPTER IV, 

OF CHRONIC DISEASES OF THE ORGANS OF DIGESTION 
AND ASSIMILATION, 

Sect. I. — Preliminary Observations, 

The chronic diseases of the Viscera of the Abdomen 
and Pelvis are more various, and demand more minute 
discrimination, and more variety of treatment, than the 
inflammations of these parts ; as may be expected, 
from the number and importance of the secreting or- 
gans contained in these parts, and from the influence 
exerted over them by the Nervous System. 
■ Some general observations, in regard to the manner 
in which these diseased states of the digestive organs 
are produced, and their connexion with other disorders, 
demand attention in the first place. 

Even when the Organs of Digestion are in perfect 
health, the symptoms of disorder there are very often 
produced, and their vital action injured, by such in- 
gesta as are beyond their powers, or by such other ex- 
citements acting on the body,— particularly on the 
Nervous System, after food has been taken, as inter- 
fere with the process by which the digestion and assi- 
milation of that food are secured. 

In studying the modes in which the organs concern- 
ed in that process may be disqualified for their office, 



580 OUTLINES OF PATHOLOGY AND PRACTICE, 



we must first attend to tlie peculiarity and complexity 
of the process itself. We speak of strength and weak- 
ness of tlie stomach ; but the process of Digestion re- 
quires the natural state of every kind of vital action ; 
and to several of these, such terms can only be ana- 
logically or metaphorically applied. The main agent 
in the first part of the process, is the Gastric Juice, 
a secretion dependent, of course, on a due sup|)ly 
and due quality of the blood, but which is likewise 
peculiarly influenced by the Nervous System; being 
only efl&cient as a solvent of the aliments, when its 
formation is duly excited by these aliments them- 
selves, and that excitation being either directly de- 
pendent on, or at least much influenced by, certain 
vital actions of the sensitive nerves of the stomach, in- 
dicated by the sensations of the stomach, and variously 
excited and stimulated by those aliments. Various 
other secretions, and a proper action of involuntary 
muscles, are required for the proper introduction of the 
aliments into the blood ; a healthy action of the or- 
gans of absorption from the Primes Vise, — i. e. both of 
veins, which seem simply to absorb fluids, and of lac- 
teals, which give occasion for the strictly vital action 
of the formation and transformation of cells, — is essen- 
tial to the transference of the nutritive portion of the 
ingesta into the bloodvessels ; and when they are in- 
troduced there, their due assimilation must depend on 
the condition of those portions of the lymph of the 
blood itself, to which they are to be added. 

Hence strength or weakness of the stomach implies 
strength or weakness, or a perfect or imperfect vital 
agency, not only of muscular parts, but of secreting 
organs, of the secreted fluids of these, of portions of 

5 



CHRONIC DISEASES OF OEGAXS OF DIGESTION, &C. 581 



the blood itself, and especially of those poriioiis of the 
Nervous System, by which the organic functions are 
continually, although variously, excited and controlled. 

Y\e know also, that the assimilation of the eJiments 
is only completed after they ha^ve passed through the 
lungs, and that much of the ultimate result, as to the 
quantity and quality of the blood formed, depends on 
the agency (still obscure, but certainly important) of 
the oxygen taken in there, and the quantity in vvdnch 
it is absorbed, as is most distinctly proved by the fact, 
that persons debarred from taking exercise require 
more aliments to maintain health and strength, than 
those who are regularly exercised. 

We know that the due assimilation of the ino-esta 
likewise depends essentially on the healthy state of 
the other organs of excretion, by which certain por- 
tions of those ingesta themselves, as well as of the pre- 
viously existing materials of the body, are continually 
expelled. 

Lastly, we know, that, along with the aliments, sub- 
stances are often taken into the system^ wdiich act 
more or less as poisons, variously affecting the nervous 
and muscular powers^ and the secreting and excreting 
organs, and thereby injuring the process of digestion 
itself as subsequently performed. 

So long and complex a vital process may of course 
be injured by causes applied in various v/aySj and at 
various points ; and the means which are truly effectual 
in restoring the na;tural condition of the function, must 
necessarily be very various, and often applied at a dis- 
tance from the stomach. 

Indeed, the processes of digestion and assimilation of 
PART III. P P 



582 OUTLINES OF PATHOLOGY AND PXJACTICE. 



food would be mucli more easily disordered than thej 
are, were it not for the beneficial influence of Habits, 
whereby this and all other actions connected with the 
Nervous System are performed with gradually increas- 
ing facility, even in circum.stances otherwise unfavour- 
able ; which provision of Nature may be truly con- 
sidered as a vis medimtrix in regard to this function. 

Functional disorders of the digestive organs, how- 
ever, very generally depend, either on the nature of the 
ingesta, or on influences communicated through the 
nerves, e. g. painful or uneasy sensations, mental irri- 
tations or anxiety, or the effect of intoxicating liquors 
or other injurious habits ; and the most effectual means 
of correcting such disorders consist, therefore, in the 
regulation of diet, and in the judicious application of 
the other articles of the Tonic E^egimen, by which, 
chiefly through the intervention of the nervous system, 
all vital action is invigorated ; particularly pure air, 
exercise, variations of temperature, especially by warm, 
tepid, or cold bathing, and mental excitement. 

Again, it is obviously important, and in some in- 
stances difticult, to understand the connexion existing 
between disorder of the function of digestion and in- 
jury or disease of other parts of the body. 

1. Disorders of the digestive organs are often the re- 
sult of changes taking place in the condition of the Nerv- 
ous System, the peculiar influence of which on the secre- 
tions must always be remembered ; as when long con- 
tinued mental languor or depression, or more violent 
mental emotion, lessens, and probably vitiates, all the 
secretions of the prim^e vice, and causes dyspepsia, sud- 
den loathing of food, or vomiting, constipation, diar- 
rhoea, sometimes jaundice, according to the constitution 



CHEONIC DISEASES OF ORGANS OF DIGESTION, &C. 583 



of individuals ; — or when the sensation of intense pain, 
in any part of the body causes thirst or dryness of the 
mouth, and destroys the power of the secretion at the 
stomach. 

2. They are often produced by deficiency of fresh air, 
exercise, and sakitary variations of external temperature ; 
which privations act primarily on other parts, producing 
long continued irksome sensations, repressing the circu- 
lation on the surface, and the different excretions from 
the body, and so favouring plethora in internal parts ; 
and likewise diminish the supply of oxygen to the blood, 
which is essential to the changes continually going on in 
its composition, and, among others, to the due formation 
of the secretions required in digestion. 

3. They are often produced by diseases, functional or 
organic, of other parts of the system, either sympatheti- 
cally, i. e, by an influence quickly communicated through 
the nerves, or more slowly but more permanently, by 
injury of the composition of the blood, or of some of the 
secretions. Such secondary affections of the digestive 
organs are often distinguished with difficulty from, and 
often mistaken for, primary ; as when various disorders of 
the stomach ensue in the course of diseases of the brain, 
liver, bowels, kidneys, uterus, or other pelvic viscera. 

4. Although not necessarily implying any alteration 
of the usual state of the circulation, yet in many cases 
they supervene on congestions of blood in the parts where 
they take place, or are aggravated by such congestions 
of blood ; as is obvious when we observe the facility with 
which Dyspepsia or Diarrhoea often supervenes on ob- 
struction to the flow of venous blood through the liver. 

5. On the other hand, a disordered state of the secre- 



5B4 OUTLINES OF PATHOLOGY AXD PRACTICE. 



tions of the stomach and bowels, injuring the digestion 
of food, often gives rise to morbid determinations and 
congestions of blood. It is thus that dyspepsia or diar- 
rhoea often assumes somewhat of the character, and is 
relieved by a moderate use of the remedies, of inflam- 
mation of the stomach or bowels. 

This is remarkably observed in certain forms of dys- 
pepsia in adults, described by Dr "Wilson Philip, Dr 
Parry, and others, in this country, and by Broussais and 
his followers in France ; and again, in many cases of 
the Febris Infantum Remittens^ formerly described as 
often depending on, or passing into, inflammation of the 
mucous membrane of the bowels. 

6. Alterations of the secretions immediately concerned 
in digestion frequently produce derangement, not only 
of the functions in which they are themselves concerned, 
but iikewise of other functions, often of distant parts ; and 
this we caai perceive to take place in three distinct ways, 
— either, ^y'd^^, when the function secondarily affected is 
necessarily dependent on that first deranged ; — or, se- 
condly^ in a niore precarious and variable w^ay, when the 
affection of the second is truly a sympathetic change ; — 
or, thirdly^ when the affection of the second is owing to 
a distempered constitution of the blood, resulting from 
the primary disorder of the Primse Vi^.- 

Thus a disordered state of the function of digestion, 
or habitual constipation or diarrhoea, leads naturally to 
deficient nutrition, and to debility and emaciation ; and 
it also leads much less certainly, but sometimes more 
obviously, to a distempered state of the external senses, 
particularly vision, — or of the mental faculties (Hypo- 
chondriasis),- — or of the respiratory actions (Asthma), — 



CHBONIC DISEASES OF ORGANS OF DIGESTION, &C. 585 

or of the voluntary muscles (Hysteria, or even Convul- 
sion), — or to various indefinite uneasy sensations com- 
mon in persons of nervous temperament. 

The spasms of the legs, attending violent diarrhoea or 
cholera, are an example of a more definite and uniform 
sympathetic effect, resulting from derangement of the 
secretions of the Primse Viee. 

But a more permanently disordered state of the organs 
of digestion and assimilation, naturally injures (although 
in ways hitherto imperfectly understood) the composi- 
tion of the blood. Hence it modifies the progress of 
inflammation, especially in a constitution already scrofu- 
lous, or of any other local disease that may be excited 
in the body, rendering it more obstinate, and less amen- 
able to treatment, as has been well illustrated by Mr 
Abernethy, Dr Hamilton, and others. In children, 
febrile action is frequently excited by derangements of 
the secretions of the Primae Vise, independently of in- 
flammation ; and in certain (chiefly scrofulous) consti- 
tutions, fever, from this cause, as from any other, is very 
apt to pass into Hydrocephalus. And in adults, the 
local diseases, depending on a morbid constitution of the 
blood, may often be ascribed, originally, to such imper- 
fect or perverted digestion and assimilation. Indeed, it 
is probably only by thus altering the constitution of the 
blood that functional disease of the stomach and bowels 
leads to the more dangerous organic diseases of these 
parts themselves. 

It may be understood from what has been stated, that 
functional disorders of the organs of digestion may be 
dangerous or even fatal in different ways, — sometimes, 
in like manner as inflammation of those organs, by 
reason of a sympathetic effect in the heart, as in cases 



586 OUTLINES OF PATHOLOGY AND PRACTICE. 

of violent Gastrodynia or violent Cholera, — sometimes 
by reason of tlie wasting and exhaustion, rapid or more 
gradual, consequent on them ; but more frequently by 
weakening the system, and aggravating, or aiding to 
produce, various other diseases, inflammatory and or- 
ganic, with which they then become complicated. 

Sect. II.— 0/* Chronic Diseases of the Stomach. 

It may be supposed, from what has been already said, 
that the different forms of Dyspepsia will be more fre- 
quent in adult age than in early youth ; more frequent, 
cwteris paribus^ in women than men ; more frequent in 
persons of sedentary occupations, and living in towns, 
than in those who breathe pure air, and follow active oc- 
cupations ; and more frequent in those whose mode of 
life is irregular, and who indulge in excesses either of 
eating or drinking, than in those who live regularly and 
temperately. But we often see the disease when we can 
assign no such cause for it. 

The symptoms of Dyspepsia vary much in different 
individuals, particularly when it is complicated with 
other disorders ; but the following may be stated as its 
most usual forms : — 

1. First, and most frequently, there are pains, usually 
a burning pain, with sense of distension and uneasiness in 
the stomach, in different parts of the abdomen, or even 
referred to various parts of the body, flatulence and acid 
eructations, beginning, in general, half an hour or more 
after food has been taken, causing much indescribable 
discomfort, and continuing while the process of digestion 
is going on ; therefore often disturbing sleep, and sue- 



CHRONIC DISEASES OF THE STOMACH. 587 



ceeded bj anorexia, often thirst, and bad taste of mouth, 
with white tongue, the next morning. 

In cases where these pains begin very soon after food 
has been taken, there is more reason to apprehend the 
existence of subacute inflammation, formerly stated as 
apt to supervene on urgent dyspepsia ; and this especially 
if there be pretty uniform tenderness on pressure (not 
merely at the time of flatulent distension), and more or 
less of hardness of pulse. 

In women, particularly during the time that they are 
subject to the menstrual discharge, it is very common 
for these symptoms to be followed by vomiting, although 
the disease be only functional : but frequent recurrence 
of vomiting in men, or in older women, may always 
excite suspicion of organic disease, either in the stomach 
itself, or in some other organ, with vfhich, as is generally 
said, the stomach sympathizes, /. e, (as we may express 
it more simply and more correctly) the diseases of which 
are attended with much nausea ; in some cases the heart, 
more frequently the brain, the liver or pancreas, or the 
kidneys. The vomiting of blood, or ha3matemesis, in 
w^omen who have suppression of the menses, is a pretty 
common consequence of this form of dyspepsia ; and in 
some cases it is seen, even to a great extent, indepen- 
dently of that cause, in cases of dyspepsia merely func- 
tional ; but more generally it depends, when uncon- 
nected with Amenorrhoea, either on ulceration of the 
Stomach or disease of the Liver or Spleen. 

2. In another form of the disease there is more acute 
pain (Gastrodynia), often attacking in sudden paroxysms, 
and often most felt when the stomach is empty, — some- 
times attended with morbid craving for food or capri- 
cious appetite, rather than anorexia — often also at- 



588 OUTLINES OF PATIIOIXJGY AND PEACTICE. 

tended with Pyrosis or eructation of an insipid fluid. 
Sometimes this intense pain is attended with unusual 
acidity and flatulence, but sometimes not. This kind of 
pahi has often the name of Spasm of the Stomach, and 
is sometimes connected with Gout. It is sometimes 
hardly to be distinguished from the pain of gallstones, 
and ought, perhaps, to be regarded as a form of Neu- 
ralgia. 

3. In other cases, the chief symptom at the stomach 
is sickness and anorexia rather than pain, but attended 
with much headache, often with giddiness, sometimes 
with suffusiones before the eyes — or with these last symp- 
toms without the headache. Such cases occur in pa- 
roxysms usually lasting two or three days, and with ir- 
regular but often long intervals; in some cases they 
certainly proceed from disorder of the stomach only, 
but in many they originate elsewhere, probably often in 
the brain. The old name Sick Headache is perhaps 
a more appropriate one than the modern name Bilious 
Headache, the appearance of bile in the matter vomited 
being in general only the result of long continued nausea, 
as in sea-sickness. 

In all these forms of dyspepsia, when uncomplicated 
with other diseases, the secretion of bile is usually de- 
ficient, often depraved, and the bowels costive. 

All forms of dyspepsia are very often attended, and 
evidently aggravated, particularly in persons of the me- 
lancholic temperament, by that morbid condition of the 
mental faculties, to which we give the name of Hypo- 
chondriasis, in which the mind dwells with inordinate 
earnestness on the uneasy feelings, exaggerates their 
importance, and anticipates danger from them. It is 
partly owing to the peculiarly oppressive nature of the 



CHRONIC DISEASES OF THE STOMACH. 



589 



sensations of dyspepsia, that tliese mental feelings so 
freqnently attend it; but in many instances it is ob- 
viously this tendency in the mind, or tlie peculiarity 
in the nervous system which accompanies it, that is 
the immediate cause of the dyspepsia; and in young- 
men particularly, merely functional dyspepsia is not of 
common occurrence, excepting in constitutions of this 
kind, where it is associated with Hypochondriasis, and 
with indescribable uneasy sensations not referred to the 
stomach. 

In other cases, particularly in women, sometimes 
along with, and sometimes without the hypochondriacal 
tendency, we see dyspepsia associated with various other 
uneasy sensations, in the bowels, in various parts of the 
surface, in the bladder, in the head ; and with the slighter 
spasms, to be afterwards described, under the name of 
Hysteria. 

All these forms of dyspepsia, although partly owing 
to known causes, suffer exacerbations for which we can 
assign no reason ; and again, although often tedious, have 
the tendency to occasional spontaneous abatement. When 
unusually urgent, we suspect that they are connected 
with the subacute inflammation of the mucous mem- 
brane formerly considered; and when they last long, 
and are attended with much emaciation and weakness, 
we apprehend that they are connected with organic dis- 
ease, either of the stomach itself, or of the viscera which 
adjoin it, or are connected in action with it in the modes 
formerly noticed. 

Even in youth, especially in young women, it is not 
uncommon to find the symptoms of dyspepsia — per- 
haps but slight — connected with ulcers on the mucous 
membrane of the stomach, which are preceded or at- 



590 orxLixES of pathology axd practice. 



tended with so little of the symptoms of inflammation, 
that they may be regarded as a form of chronic organic 
disease; and these may be snddenly fatal, either by ero- 
sion of a bloodvessel, and haemorrhage, or (more fre- 
quently) by perforation of the coats, escape of the con- 
tents of the stomach, and rapid peritonitis. 

The other cases of organic disease of the stomach are 
most generally seated either at the Cardia, or near the 
Pylorus. In the former case, we have the pain and 
difficulty felt 'on the morsel of food passing into the 
stomach, and after a time very generally partial regur- 
gitation of food. In the latter case, we have the ac- 
cession of pain at regular times, — generally from two 
to three hours after food is taken, followed and relieved 
by the periodical vomiting; the matter vomited often 
becoming ultimately of the dark brov\'n or blackish 
colour. In the case, not uncommon, where the stomach 
becomes greatly distended and enlarged, the vomiting- 
is not so frequent or regular, but is occasionally to an 
enormous extent. In both cases, but especially in the 
latter, we may have, after a time, a small firm tumour 
perceptible to the finger, and somewhat tender on pres- 
sure, at the seat of the disease ; which, however, is 
sometimes considerably moved from its natural position. 
Such diseases of the stomach are generally attended 
with obstinate costiveness. 

The adventitious textures, which are deposited in the 
stomach in such cases, usually originate in the cellular 
texture uniting the coats. They vary exceedingly from 
simple induration and thickening of this texture, to the 
formation in it of circumscribed tubercles of malignant 
character, most frequently either of the encephaloid kind, 
or of the true scirrhus, or sometimes of melanosis. They 



CHRONIC DISEASES OF THE STOMACH. 



591 



are very generally attended, after a time, by nlceration 
of the portion of mucous membrane immediately above 
them, which sometimes becomes very extensive, not un- 
frequently perforating all the coats of the stomach, and 
either leading to effusion of its contents and suddenly 
fatal peritonitis, or prevented from causing this termi- 
nation only by adhesion of neighbouring viscera. When 
they occur in constitutions evidently much impaired, 
and where we believe that the blood is tainted with dis- 
ease, — and when they have lasted some time, — they are 
to be regarded only as objects of palliative practice. 

Another form of organic disease nearly peculiar to 
the stomach, is that which consists essentially in soften- 
ing of the mucous membrane, without the absolute de- 
struction of that membrane, or the hardened, usually 
elevated edge of the diseased part, to be seen in ulcera- 
tion. The partial softening of this membrane, seen 
after death, is indeed very often a post mortem or 
pseudo-morbid appearance, the consequence of death hav- 
ing taken place suddenly during digestion, ^. e, at a time 
when the active gastric juice exists in the stomach. 
But there are cases, both in children and adults, where 
there are severe dyspeptic symptoms and much vomit- 
ing, in children both vomiting and diarrhoea, and the 
body is sometimes much weakened and emaciated, and 
death takes place either with the symptoms of sudden 
rupture, or by gradual exhaustion ; and where this mor- 
bid softening is the chief or only morbid appearance. 
This softening may probably be ascribed to a morbid 
condition, and generally an unusual acidity, of the se- 
creted fluid, which shews itself by giving a black colour 
to the blood in the vessels of the part. 



592 OUTLINES OF PATHOLOGY AND PRACTICE. 



The treatment of the merely fmictional Dyspepsia may 
be said to consist essentially of two parts, — the relief 
of symptoms by medicines, and the removal of the re- 
mote causes of the disease by diet and regimen. The use 
of medicines to strengthen the stomach, L e, to counteract 
directly or specifically the injurious effect of these causes, 
is not to be neglected, but cannot be much relied on. 

The medicines which are most effectual for the re- 
lief of the symptoms of dyspepsia are — 

1. The Antacids, w^here there is much acidity and 
burning pain, particularly soda, magnesia, and bismuth, 
the latter of which seems in some persons to have a 
more specific power as to pain and sickness at stomach. 

2. Carminatives, to relieve the distension from flatu- 
lence, whether the effect of fermentation of the aliments 
or of secretion, particularly preparations of ammonia, 
volatile oils, and ether, 

3. Laxatives, particularly such as act gently and re- 
gularly, imitating as to their time of action the natural 
process, and promoting, as far as we can jndge, the se- 
cretion of bile, but not causing any considerable increase 
of the mucous or watery secretions of the bowels. 
Mercurial preparations, in combination with other laxa- 
tives, seem to have a certain degree of peculiar power 
in exciting the secretion of bile, but the amount of this 
has been much exaggerated. 

4. Anodynes, e. g, the Hydrocyanic Acid and Mor- 
phia, especially the Opiate Enema, where the pain or 
sickness and vomiting are peculiarly urgent, care being 
taken as to the latter that its use be restricted to the 
times when either pain or sickness is urgent, and, 
therefore, chiefly to the second variety above stated, 
and that its constipating effects be corrected. The 



CimOXlC DISEASES OF THE STOMACH. 593 



Creosote, in some persons, acts nearly as an anodyne in 
regard to vomiting ; and warm applications assiduously 
used, or even counter-irritants applied to tlie epigas- 
trium, are likewise useful in this way. 

The medicines which seem to have most power in 
restoring the natural functions of the stomach when the 
appetite and digestion are much impaired, without organic 
disease, are the preparations of Steel, and the bitters, 
Quinine, Gentian, Quassia, or Colombo, which seem in 
general to answer best when combined with such quan- 
tity of laxative medicine as may act once or twice, and 
not more frequently, in twenty-four hours. The Quinine 
and Steel, and perhaps especially the Carbonate of Iron, 
seem to be peculiarly useful in the second variety, when 
the pain attacks in paroxysms resembling neuralgia of 
other parts ; and the preparations of steel are pecuharly 
indicated when there is Amenorrhcea. 

It w^as formerly stated that there are many cases in 
which the tenderness on pressure, the pain immediately 
on food being taken, and the state of the pulse, indicate 
an inflammatory action in the mucous membrane, and in 
which local bloodletting, sometimes even small general 
bleedings, blisters, and antiphlogistic diet, should be pre- 
mised to the use of any other means. 

There are also cases of obstinate character, and be- 
ginning to resemble the organic disease at the Pylorus, 
in which Mercury, particularly in the form of Calomel 
and Opium, taken so as to affect the mouth, with pre- 
cautions against exposure to cold, and against exces- 
sive action on the bowels, is certainly and signally 
useful; but if this benefit is not observed within a few 
days after the mouth has been affected, it may be inju- 
rious to the general health to continue this remedy. 



594 



OUTLINES OF PATHOLOGY AND PEACTICE, 



The essential articles of regimen, proper for dyspep- 
tic patients, are tlie following : — 

1. The diet should be such as will give the most 
nourishment with the smallest risk of exciting the uneasy 
sensations of indigestion, or irritating and so injuring, 
the secreting surface. We know that a diet chiefly 
vegetable, and of soft consistence, may give an insuffi- 
cient stimulus to the secretion, even for its own solution ; 
and on the other hand, that more solid food, in larger 
proportion animal, may require more gastric juice for its 
solution than the stomach can furnish ; and we must 
steer between these difficulties according to the circum- 
stances of individual cases, observing, in general, the 
following rules : — 

1. That there should be a miKture of animal and 
vegetable food, or more correctly, a mixture of azotized 
and non-azotized substances (all vegetable matters capa- 
ble of nourishing animals being now believed to contain 
albuminous matters identical in composition with the al- 
bumen of animals), — if possible a mixture of albuminous, 
saccharine and oily matters in each meal. There seems 
to be reason for believing, according to the statements 
of Liebig, that the first of these, the azotized aliments 
only, are directly concerned in nutrition ; but the others 
are required for combination with oxygen, for the excre- 
tion of carbonic acid and water, and the maintenance 
of animal heat, which is attended w4th the conver- 
sion of the residuary non-azotized aliments into fat ; and 
afterwards, if the supply of those non-azotized aliments 
is diminished or stopped, this fat is acted on by the oxy- 
gen, thus maintaining the heat of the body, and at the 
same time protecting the tissues which are of more essen- 
tial use to the economy, from the destructive action of 



CHRONIC DISEASES OF THE STOMACH. 



595 



the oxygen. If these views are confirmed, they will go 
far to explain the fact, which seems at all events to be 
ascertained, — that a mixture of azotized and non-azotized 
matters in the aliment is necessary to life. 

2. That these substances be taken in a state of medium 
aggregation, very soft matter giving little stimulus to 
the secretion, and substances thoroughly dried and 
hardened being difficult of solution in the gastric juice. 

3. That the quantity of the oily or fatty constituents 
of the aliments be much less than of the others ; — all 
such substances being difficult of digestion. 

4. That the times of taking food be regularly kept; 
the intervals being such as the previous experience of 
each individual may shew to suit his digestive powers ; 
for in this respect there is much variety in individuals, 
those of middle age raid of the strongest habit usually 
taking the largest quantities, and requiring the longest 
intervals for the perfect assimilation of their food. 

5. That regular and early hours of sleep be enjoined, 
in order that much of the process of digestion of the 
food taken during the day, may be allowed to go on 
during sleep, and again, that so m.uch sleep be not al- 
lowed, as to favour an excessive formation of fat. 

6. That the quantity of fermented or spirituous 
liquors allowed be small, such as may give only a gentle 
stimulus to the secretion of the stomach, and have no 
permanent sensible effect on the Nervous System. 

7. That any peculiarities of constitution as to the ef- 
fect of particular substances on the stomach, if carefully 
observed, be consulted. 

8. On the other hand, that care be taken not to en- 
courage dyspeptic patients to dwell on their uneasy sen- 
sations, or make their complaints objects of solicitude., 



59G OUTLINES OF PATHOLOGY AND PrvACTICE. 



lest the hypochondriacal tendency be increased or con-^ 
firmed. 

The other articles of Regimen, ^vhicli are of essential 
'importance to dyspeptic persons, are, 

1. Exercise of the volnntary muscles in pure air^ not 
violent or irritating, especially in feeble persons, nor so 
long continued as to fatigue, — but steadily continued, re- 
peatedly in the day, ^ith a view to the following effects, 
clearly attributable to it. First, That a full supply of 
oxygen taken in at the lungs, and certainly important 
for the assimilation of the aliments, be maintained. 
Secondly^ That the circulation be encouraged to the 
muscular parts of the body, the surface and extremities, 
and congestions of blood in internal parts averted. 
Thirdly, That the secretions, not only, on the surface, 
but of internal parts, required in digestion, and espe- 
cially that of bile, be duly supported and stimulated : 
And, fourthhf, That the mind be so occupied as to dimi- 
nish its tendency to dwell on internal uneasy sensations. 

2. Such use either of the warm bath, the tepid, or the 
cold bath, as may appear most effectual for maintain- 
ing vigorous circulation on the surface of the body, 
and securing a frequent recurrence of grateful sensa- 
tions there. 

3. Chiefly as a means of inducing patients to take 
exercise with animation, and mental gratification, occa- 
sional changes of scene and mode of life. 

4. Temporary relaxation from care and mental la- 
bour, and gentle mental excitement, by occupations in 
which interest is taken, especially if in the open air, 
and by all justifiable means of exciting the pleasing 
emotions of hope and confidence. 

It is still a question how far large draughts of vrater, 



CHRONIC DISEASES OE THE STOMACH. 597 



either pure, or with slight saHne, sulphurous, or chaly- 
beate impregnations, or of the different mineral waters, 
assist the effect of these means on the digestive organs ; 
but it seems to be certain, that such quantities of watery- 
fluids are only proper when the excretions are at the 
same time promoted, particularly by exercise. 

Great varieties of temperature are compatible with a 
very healthy state of the digestive organs ; but the ener- 
vating effects of extreme heat, and the depressing effect 
on the nervous system, or the revulsive effect on the 
circulation, of cold, especially applied to the extremi- 
ties, are to be carefully avoided. 

The organic diseases of the stomach, when they have 
lasted some time, and led to much wasting, or when the 
previous health of the patient gives reason to suppose 
that they are parts of a constitutional and probably ma- 
lignant disease, are properly objects only of palliative 
practice, by regulation of diet and regimen, and by the 
frequent use of opium, and other anodynes, alternated 
with the mildest laxatives. But there are some cases 
in which recovery from these symptoms has taken place, 
after considerable emaciation, under the cautious use of 
Mercury and of Iodine, particularly the former; and 
a greater number, where these symptoms, in young 
women, have been connected with Amenorrhoea, and in 
which the persevering use of Steel, and other Emmena- 
gogues, with so much of the Tonic Regimen as was ad- 
missible, has been completely successful. 

In such aggravated forms of Dyspepsia, not only 
much of the requisite laxative or anodyne medicine, is 
best given in Enema ; but nourishing Enemata, re- 
peated once or twice daily, even for some weeks to- 
gether, are a resource of great value, preventing the 

PAET III, Q q 



598 OUTLINES OF PATHOLOGY AND PEACTICE. 

patient from sinking, until after a fair trial is made of 
complete abstinence from all stimuli or irritations af- 
fecting the stomach. 

Sect. III. — Of Chronic Diseases of the Liver, Pancreas, 
and Spleen. 

Two Functional diseases of the Liver are well known ; 

those of the Pancreas or Spleen, cannot be accurately 
distingTiished. Those to be noticed are the Cholera, and 
certain kinds of Jaundice. 

I. The common Cholera of this country consists es- 
sentially in an overflow of Bile, shewn by frequent copious 
vomiting and purging of matter containing much bile, 
and is most generally produced, at least in part, by the 
peculiar effect of heat on the liver ; it is therefore most 
common in hot weather, occurring however, now and then 
at all seasons, sometimes from obvious excess in diet, 
sometimes without obvious cause. It generally begins 
suddenly, and is often attended with severe internal 
pain, not, however, of inflammatory character, with 
cramps of the calves of the legs, and with rapidly in- 
creasing debility, going on in a few days, or even hours, 
to coldness of surface, clammy sweats, and feeble or 
nearly imperceptible pulse. 

A short delay is proper, after the disease has com- 
menced, before means are employed to check the dis- 
charges, lest morbid bile or other irritating matters be 
pent up in the body, and during that time diluents only 
are proper ; but before the patient becomes feeble, re- 
course should be had to Opium, in full and repeated 



OF CHRONIC DISEASES OF THE LIVER, &C. 599 



doses, chiefly in pill, by which the disease, if uncom- 
plicated, may very generally be arrested . In cases where 
the circulation has been much enfeebled before this treat- 
ment is begun, the assiduous use of stimuli, externally and 
internally, is often required before the patient rallies. 

II. Jaundice, distinguished by the yellow colour of the 
skin and eyes, the dark brown colour of the urine, and 
whitish colour of the fseces, depends on very various 
causes, and admits, therefore, of very various prognosis. 
It is to be regarded as a merely functional disease of the 
liver in three cases. 

1. It may proceed from a merely thickened and viscid 
state of the bile, impeding its own descent through the 
ducts, and leading to its reabsorption, particularly when 
much of it has been long stagnant in the gall-bladder. 
Such cases are chiefly to be expected in persons of se- 
dentary habits, especially succeeding to a more active 
mode of life, when the appetite and digestive powers have 
become deficient, and the descent of bile, already se- 
creted_, is not solicited, as in the more active state of the 
digestive organs, by the passage of chyme along the 
duodenum. This cause of jaundice may be suspected 
when the health has been previously good, when no 
pain, swelling, or other indication of diseased liver exists, 
and no cause, except such habits as have been mentioned, 
can be traced ; and it may be known by the appearance 
of dark viscid bile in the stools, contemporaneous with 
abatement of the symptoms. 

2. Jaundice may proceed from longer delay and in- 
ternal changes in the bile in the gall-bladder, leading to 
the formation of Calcuh, consisting chiefly of Cholester- 
ine, to which portions of inspissated bile have adhered, and 



600 OUTLINES OF PATHOLOGY AND PRACTICE. 



which become fixed in, and obstruct the ducts, and pro- 
duce the symptoms of Icterus Calculosus, i. e. J aundice, 
attended by paroxysms of sudden and violent pain, with 
vomiting, referred to the pit of the stomach, without 
frequency of pulse or tenderness on pressure, although 
rigors and faintness often attend the intense pain. 

It may be easily understood that the obstruction to 
the descent of the bile by the gall-stones may be only 
partial, either in consequence of the obstruction being 
only in the Cystic duct, or of the form of the calculus 
allowing the descent of part of the fluid ; and therefore, 
that a paroxysm of this disease may be attended with 
but little yellowness, or even with none, especially if the 
disease has repeatedly recurred, and the ducts become 
permanently enlarged. 

It may be easily understood, also, that the obstruc- 
tion of the ducts by the calculi may often lead to in- 
flammation there, which may extend from the obstructed 
point ; and therefore, that more or less of the symptoms 
of Hepatitis or Peritonitis may supervene on aggravated 
cases of these calculi. 

Such cases often occur without any obvious cause ; but 
in many instances they are obviously dependent on the 
same causes as the last species, particularly a sedentary 
life and long-continued depressing passions of mind, affect- 
ing, in certain constitutions, this secretion more than 
others. Any cause of congestion of blood in the liver 
(such as has been described as frequently resulting from 
organic disease of the chest) may become a cause of 
gall-stones. There being some cases of jaundice, from 
organic disease, attended with paroxysms of intense pain, 
the only absolute proof of its dependence on calculi is 
the appearance of these in the stools. 



OF CHEONIC DISEASES OF THE LIA'EE, &C. 601 

3. It is quite certain, that, in other cases, jaundice is 
produced in a very different way, but likewise indepen- 
dently of obvious change of structure of the liver ; viz. 
by suppression of the secretion, not obstruction to the 
excretion, of the bile ; this, like other excretions, being 
formed in the blood, and only evolved at the liver, and 
therefore accumulating in the blood, when its separation 
at the liver is suspended, as the urea does in cases of 
failure of the function of the kidneys. That this may 
happen, we know, from fatal cases of that kind, in 
which, on dissection, the liver has appeared sound, and 
the bile ducts pervious and empty ^ implying that the se- 
cretion has been suspended. The existence in the blood 
of matters destined to excretion, in this as in other 
cases, is properly to be regarded as a disease of the organ 
intended for their excretion, although the formation of 
such matters in undue quantity, or with morbid qualities, 
is properly a disease of assimilation, or of absorption. 

The fatal event, in cases of this kind, is always pre- 
ceded by delirium, spasms, and coma, — not explained by 
any thing found, on dissection, in the brain, and indicat- 
ing that the retained bile, like retained urea, acts as a 
narcotic poison on the nervous system. From compa- 
rison of these with many cases of long-continued jaundice, 
from obstruction of the ducts, without any affection of 
the brain except drowsiness, it may be inferred that the 
retained bile is more injurious than that which is 
absorbed^ and probably altered in that process. This 
case is to be distinguished from that of jaundice with 
pervious ducts occurring in the course of fever, some- 
times also in cases of inflamed veins, in which the 
secretion of the bile is not suspended, the stools being 
all along loaded with bile, — in which, therefore, we must 



602 OUTLINES OF PATHOLOGY AND PRACTICE. 



suppose that an increased formation of bile takes place 
throughout the system. 

But we can, of course, have no proof that all cases 
of the suspension of the secretion of bile are fatal ; and 
it may be suspected, from the cases we see of jaundice, 
even long continued, abating gTadually without any 
cause of obstruction ever appearing, in the stools or 
elsewhere, that, in some constitutions, probably when 
other excreting glands are active, the retained excretion 
may be otherwise expelled, and the patient survive even 
a pretty long suspension of the secretion of bile. 

Cases of jaundice, from this cause, may almost always 
be traced to violent mental emotions. This cause of 
jaundice may be suspected, when it occurs suddenly from 
that cause, and without indications either of calculi, or 
inflammation, or organic disease. The old notion of 
their depending on spasm of the ducts, is obviously in- 
admissible ; but the nature of the disease, although it 
may often be suspected, from the attack of cerebral 
symptoms, can only be certainly known by post mortem 
examination. 

In all cases of jaundice, there is necessarily much in- 
terference with the process of digestion and assimilation 
of food, although the exact province of the secretion of 
bile, either in that process or in those chemical changes 
which end in the evolution of carbonic acid, and main- 
tain the animal heat, is still somewhat doubtful : more 
or less of emaciation and weakness therefore always at- 
tend it, but the affection of the appetite is more various, 
it being frequently altered or perverted, rather than 
diminished. 

In the uncertainty which often exists in regard to the 
cause of jaundice, unattended with obvious organic dis- 



OF CHROXIC DISEASES OF THE LIVER, &C. 603 

ease, the prognosis may be said to be generally good, 
unless such affections of the nervous system as are no- 
ticed in the account of this last variety shew themselves. 
When they occur, the case is nearly hopeless, although 
they have been seen to abate under the use of strong 
purgatives and mercury acting fully on the system. 

In all cases of Jaundice, it is right to act steadily and 
regularly on the bowels for some time ; and if the disease 
is obstinate, and no adequate cause appears. Mercury or 
other alteratives. Iodine, Taraxacum, Sulphurous waters, 
may be tried; but if the health has been previously 
good, and no affection of the nervous system shews itself, 
it may be confidently expected that the disease will gra- 
dually abate, and any such remedies as may weaken or 
otherwise injure the constitution ought to be avoided. 
The use of such articles of the Tonic Regimen as may 
appear feasible, particularly of exercise, light but nourish- 
ing diet (excluding oily matters), the excitement of 
change of scene, and the stimulating influence of exter- 
nal heat on the liver, are to be advised. 

In the paroxysms of the Icterus Calculosus, much re- 
liance may be placed on full doses of Opium, chiefly 
given in enema, with external warmth or the warm 
bath ; alternated, of course, with the laxatives ; but we 
can expect little or nothing from Turpentine, Ether, or 
any other means intended to affect the composition of the 
bile in the ducts ; and we may regard the use of Eme- 
tics as very generally hazardous. 

There are many cases of stomach complaints, as well 
as of diseases of other parts of the system, connected with 
disordered stomach and bowels, which have been supposed, 
of late years, to originate in a disordered or torpid condi- 



G04 OUTLINES OF PATHOLOGY AND PRACTICE. 



tioii of the Liver, indicated by deficiency or a morbid ap- 
pearance of bile, generally of a very dark colour, in tbe 
stools ; and to be, in consequence of dependence on that 
cause, more effectually relieved by Mercury than any 
other means : but the evidence of a morbid condition of 
the bile, with which many have been satisfied, is defec- 
tive ; and we have so little means of judging how far 
derangement of the function of digestion, unconnected 
with structural alteration in the liver, can be the re- 
sult of altered or deficient action there, or how far such 
deficient action may be only a part of the general de- 
rangement — that the only practical rule which we can 
deduce from such observation is, that the appearance of 
the bile in the stools, as well as the regxilarity of action 
of the bowels, demands attention in all cases where the 
digestion is much impaired. The combination of mer- 
curials with other laxatives, appears sometimes pecu- 
liarly (although it is certainly by no means exclusively) 
effectual in restoring the natural appearance of the 
stools ; and that change, when distinctly observed, is 
certainly often very favourable, whether we are to re- 
gard it as the cause or the sign of a more general re- 
covery of the powers of digestion ; but these facts do 
not justify the indiscriminate use of Mercury, sometimes 
adopted in such affections, in cases where no immediate 
benefit from it results, and where its ulterior effects on 
the system may be very injurious. 

The most common Organic disease of the Liver 
is the Granular Degeneration, sometimes appearing as 
the result of pretty distinct inflammation, often gra- 
dually effected without inflammatory symptoms ; begin- 
ning apparently as simple increase, or hypertrophy, of 



OF CHRONIC DISEASES OF THE LIVER, &C. 605 



the grey cellular texture, and passing ultimately, in ag- 
gravated cases, into the state described as Cirrhosis, in 
which the whole organ is often shrunk and corrugated, the 
glandular substance nearly absorbed away, its place occu- 
pied by irregular clusters of brownish-yellow tubercles, 
and the whole circulation in the liver, as injections de- 
monstrate, very much lessened. These changes appear, 
on minute examination, to consist essentially in the de- 
position and growth of minute granules on the mem- 
branous and very attenuated and convoluted prolongations 
of the Capsule of Glisson, which extend throughout the 
substance of the gland enveloping every one of the acini. 
This affection of the liver may generally be held to be 
constitutional, and often symmetrically afiFects different 
parts of the organ ; but it is not usually of malignant 
character, especially when it results from causes which 
determine local congestions of blood, without implying 
change of its constitution, such as chronic disease of the 
heart or lungs, or frequent paroxysms of intermittent 
fever. In different cases (by reason especially of the 
complex nature of most such), death takes place in very 
different stages of this progress ; and many modifica- 
tions of these changes are also observed. In scrofulous 
cases, the liver is sometimes infiltrated with matter, in 
its first stage, of nearly opaline lustre ; in some instances 
it is enlarged and much hardened, with ^little change of 
colour; in others it undergoes the fatty degeneration 
formerly mentioned ; or is simply softened without other 
change of texture. 

In other cases, large and distinct tubercles form in 
parts of the liver, while others are of natural structure ; 
and there are three kinds of morbid growth, which may 
be easily distinguished from the more usual changes in 



606 OUTLINES OF PATHOLOGY AND PRACTICE. 



tlie liver, — tlie effusion of clots of blood, which gra- 
dually change into various kinds of tumor, — the cysts 
or sacs containing Hydatids, — and the Encephaloid de- 
posits, or Medullary Sarcoma (Tubera diffusa of Farre), 
which soften in the centre, and are generally attended 
by similar deposits in other parts. 

The large white tubercles of this last description, but 
considerably various in consistency and aspect, are in 
general very little dependent on any local cause, and 
are the most truly malignant of the adventitious textures 
here found. 

The Bile in these different diseased states of the liver 
is often scanty, and either lighter or darker coloured 
than natural ; but the alterations which it undergoes 
have not been carefully examined. In most of those 
cases, where a considerable portion of the substance of 
the liver remains sound, the bile is of natural appear- 
ance and quantity ; and in some of those where its 
whole structure is diseased, the alterations of the secre- 
tion are much less than might have been expected. 

From what has been already said, it will be under- 
stood, that such organic lesions of the Liver are chiefly 
to be expected in persons somewhat advanced in life ; 
and that the tendency to them is remarkably given by 
chronic diseases of the heart or lungs, by intermittent 
fever, by the habitual use of distilled spirits, and by re- 
sidence in warm climates, especially in circumstances 
otherwise favourable to the formation of organic dis- 
ease. 

The symptoms attending such organic lesions of the 
liver, especially when they do not distinctly commence 
with marks of inflammation, are extremely various. 
The most certain is perceptible enlargement of the or- 



OF CHRONIC DISEASES OF THE LIVER, &C. 607 



gan, with dull sound on percussion, as far down the ab- 
domen as the diseased organ stretches ; but this enlarge- 
ment may be absent throughout a case of the worst kind, 
and often disappears in the later stages of cases where it 
was at first distinct. In some cases an enlargement up- 
wards, forcing up and encroaching on the lung, as high as 
the fourth or third rib, may be detected, and distinguished 
by the attendant symptoms from a chronic pleurisy of 
that side, although the liver do not project beyond the 
margin of the false ribs. When there is no enlarge- 
ment, the difficulty of lying on the opposite side is not 
to be expected. Sharp pain in the hypochondrium or 
shoulder, seems to be an accidental, and not a very com- 
mon, attendant of any kind of these deposits. Jaundice 
is only to be expected, if there be pressure on some of 
the gall- ducts; which is neither constant, nor, if pre- 
sent, necessarily permanent ; nor is it the effect of or- 
ganic disease of the liver only. A sallow though not 
jaundiced complexion is very often observed, but is by 
no means peculiar to organic disease of the liver. The 
alterations of the alvine evacuations are various, and, 
agreeably to what is stated above, are sometimes absent, 
even when great alteration of the substance of the liver 
exists. And the dry cough, and confined breathing on 
the one hand, or the sympathetic affections commonly 
referred to the stomach, anorexia, thirst, dryness of 
tongue, sense of oppression, flatulence and acidity, nau- 
sea and vomiting, on the other, though often obvious 
and distressing, are neither uniform nor characteristic. 
The existence of organic disease of the liver is therefore 
often a matter of probability, rather than of certain 
knowledge, and gathered from observation of two or 
more of the symptoms above noted, rather than inferred 



608 OUTLINES OF PATHOLOGY AND PEACTICE. 



from any one pathognomonic symptom. In many cases, 
tlie most pathognomonic symptom is a peculiar smell 
of the breath, easily distinguished, and distinctly per- 
ceived over the diseased liver in the dead body. The 
nature of the organic affection is of course still more 
obscure ; but it may be stated, that, in a constitution 
previously healthy, and when such a cause exists for 
liver disease, as organic obstruction in the chest, and 
especially if the symptoms have been originally inflam- 
matory, we may generally expect the induration by small 
granular deposits only ; and that when the health has 
been otherwise long infirm, and perhaps especially when 
the stomach is much afiPected, the encephaloid, or other 
constitutional morbid structure, may be suspected. 

The greater number of such organic alterations of the 
liver must necessarily obstruct more or less the flow of 
blood in the vena portse, and hence they act very gene- 
rally as a great predisponent cause, and sometimes as 
the only perceptible cause, of farther diseases of the ab- 
domen, which frequently contribute to indicate their ex- 
istence. These are, 

1. The efl*usion of serum into the cavity of the abdo- 
men, constituting Ascites. 

2. The increased flow of the mucous secretion of the 
intestines (common in the warm climates), constituting 
mucous Diarrhoea, but easily aggravated into the form 
of Dysentery. 

3. Bloody discharges from the primse vise, i. e. Hse- 
matemesis, Meleena, or Hsemorrhois, or a combination 
of these. 

The debility and emaciation consequent on those or- 
ganic diseases of the liver, which are attended with the 
greatest sympathetic aff'ection of the stomach, nausea 



or CHRONIC DISEASES OF THE LIVER, &C. 609 



and vomiting, sometimes go on to a fatal termination, 
without any of these ulterior consequences ; but more 
generally either dropsy, and consequent dyspnoea, or 
mucous or bloody diarrhoea, has existed for some time 
before death. In all kinds of severe affection of the 
liver, it sometimes happens that a sudden attack of 
coma, not always explained by effusion within the cra- 
nium, takes place. It is uncertain whether this can 
be ascribed, as in the case of disease of the kidneys, to 
retention of matter destined to excretion. 

When organic disease of the liver has gone a certain 
length, it is only an object of palliative practice, and no 
doubt there are many cases, particularly where the ma- 
lignant deposits have taken place in it, which are of 
that kind from the first. But we have good evidence 
that a certain degree of disease of the liver, probably 
especially of the common granular deposits going on to 
Cirrhosis, may be controlled by remedies and regimen. 

The regimen required is a light diet, with only a very 
moderate allowance of animal food, and that of the kinds 
noted as easiest of digestion, without fat or oil, and with 
little or no strong liquor ; and much moderate exercise 
in pure air. The medicines which have seemed most 
effectual are : — 1. Mercury, given so as to affect the 
mouth for some days or weeks, not to be urged, how- 
ever, in constitutions which seem to be irritated by it. 
2. Saline and sulphurous laxatives in moderate quan- 
tity, but steadily employed, as at Harrowgate, Chelten- 
ham, Airthry, &c. 3. Other supposed deobstruents, pre- 
parations of iodine, sarsaparilla with alkalis, taraxacum, 
the nitro-muriatic acid, and, according to the German 
physicians, the muriate of ammonia. 



610 OUTLINES OF PATHOLOGY AND PRACTICE. 



It has been already explained, that the Spleen is af- 
fected with organic disease most generally at the same 
time, and in the same manner as the liver, more re- 
markably as a sequela of intermittent or remittent fever 
than in any other case. In some instances it is the seat of 
morbid deposits, or of simple Hypertrophy (sometimes 
going to an enormous extent) when the liver is sound. 
Such affections of the spleen have been sometimes found, 
as the chief morbid appearance, when there has been 
much vomiting, a peculiarly pallid complexion, and great 
and progressive emaciation and debility. Tumors of the 
spleen produce local symptoms chiefly by reason of their 
pressure on, and interference with the functions of, 
neighbouring parts ; and they have been often observed, 
as may easily be understood from the vascular connec- 
tions of the organ, to be attended with attacks of Hse- 
matemesis, which have been followed by sudden reduc- 
tion of the swelling. 

The most important practical observation on organic 
diseases of the Spleen usually made is, that they are 
seldom benefited by mercury, which very often acts vio- 
lently on those subject to them ; and that blisters and 
combinations of laxatives with bitters and chalybeates, 
have generally appeared the most useful remedies. 

The Pancreas has been often found affected with dif- 
ferent organic diseases, perhaps chiefly in cases where 
other organs were at the same time similarly affected ; 
but the symptoms have appeared at least as obscure, 
and the degree of affection of the function of digestion 
at least as variable, as when the liver has been organi- 
cally diseased ; and many of the symptoms, obvious in 
some cases, have evidently proceeded from compression 
of adjoining organs, as jaundice from obstructed gall- 



OF CHRONIC DISEASES OF THE INTESTINES. 611 



ducts, pulsation from compressed aorta, pain of back 
probably from stretched or injured nerves. No re- 
medies can be pointed out as peculiarly applicable to 
diseases of tbis organ. 

In regard to all the organic diseases now mentioned, 
it is to be observed, that watching for attacks of sub- 
acute inflammation, and applying the remedies for them 
early and moderately, are among the most important 
objects of practice. And another important practical 
observation is, that all of them are often observed to 
abate in an extraordinary degree, particularly in their 
earlier stages, from change of scene and of climate. 



Sect. IV. — Of Chronic Diseases of the Intestines. 

Two important Functional diseases here first claim our 
attention. Diarrhoea and Constipation, usually attended 
with pain, and described under the name of Colic, both 
of which, however, when unusually violent or obstinate, 
may always excite apprehension of organic disease. 

I. The sub-acute forms of inflammation of the mucous 
membrane of the bowels, being often attended with little 
pain, are sometimes not easily distinguished from cases 
of simple Diarrhoea, and some have supposed that there 
is no diarrhoea without inflammation of that membrane ; 
but Andral and others have shewn that diarrhoea may 
be fatal, without any mark of inflammation being left in 
the body ; and the experience of the juvantia et leeden- 
tia leaves no room for doubt as to such diarrhoea fre- 
quently occurring, idiopathically as well as symptomati- 



612 



OUTLINES OF PATHOLOGY AND PRACTICE. 



cally, although in the former case it is not frequently 
fatal. 

Such diarrhoea is more easily produced in infants and 
children than adults ; it is most common in hot weather, 
and is often excited either by improper diet, — particu- 
larly raw acescent, or ill prepared vegetable food, — or 
by cold, applied about the feet. In young children it is 
often produced by the irritation of teething ; but in 
such cases there are generally some febrile symptoms, 
and, in the commencement at least, some inflammatory 
tendency. 

The origin of the disease, in cases of diarrhoea, is pror- 
bably always an increase either of the secretions poured 
into the duodenum, or of those of the mucous membrane 
of the intestines, most frequently of the latter ; and the 
inordinate action of the muscular coat is brought on 
secondarily. 

In children, the increased secretion of mucus is often 
attended, after a time, by enlargement of the ducts of 
the mucous glands and follicles ; and the quantity of 
mucus thrown out gives a light colour to the stools, 
even when the liver is secreting a full quantity of bile, 
— which, however, has been often mistaken for an indi- 
cation of torpor of the liver. 

This increased secretion of mucus is often the means 
by which, particularly in children, a morbid quantity of 
the earthy phosphates, existing in the blood, is expelled 
from the body, and when not passing out of the intes- 
tines, this mixed fluid sometimes acts as a cement, by 
which, with residuary alimentary substances, such as the 
husks of oats, intestinal calculi are formed. 

It is always to be remembered also, that Diarrhoea, 
especially when alternating with fits of colic and con- 



CHRONIC DISEASES OF THE INTESTINES. 



613 



stipation, is often a result of organic diseases, of the 
kinds to be noticed under the next head, particularly of 
such as involve deposition on, or ulceration of, the mucous 
membrane of some part of the intestines. 

in some constitutions, Diarrhoea is also easily pro- 
duced, not only in the course of febrile and inflammatory 
diseases, but of chronic, and especially organic diseases 
of other parts; which, therefore, may always be suspected 
when diarrhoea is obstinate. In particular, it is often a 
concomitant of the granular disease of the kidney when 
that is unattended by dropsy ; and then it is probably 
the channel, by which much of the retained urea passes 
out of the system, and is prevented from exerting its 
noxious influence on the brain. Its frequent connection 
with the suppurative stage of inflammation, with scrofu- 
lous disease, either of the abdominal viscera or of the 
lungs, or of other parts, and the partial inflammation, 
tubercular deposits, or ulceration, generally found in such 
cases of colliquative diarrhoea, have been already consi- 
dered. 

As it sometimes results from improper aliments, and 
perhaps sometimes from diseased secretions, which it 
does not fully expel, Diarrhoea is sometimes most effec- 
tually checked by a mild laxative ; but the continued use 
of laxatives in cases of diarrhoea is often very injurious, 
and in a great majority of cases, — even when attended 
with some febrile symptoms, as is very common in young 
children, — it is most beneficially restrained, after it has 
lasted a day or two, by repeated moderate doses of 
opiates and astringents, particularly Chalk, and Lime- 
Water ; the vegetable astringents, such as Kino, Catechu, 
PART III, R r 



614 



OUTLINES OF PATHOLOGY AND PRACTICE. 



or decoction of Logwood ; or the mineral astringents, 
sucli as acetate of lead, the latter of which has the ad- 
vantage, in small doses, of hardly ever causing sickness. 

II. Colic has also a strong affinity to abdominal in- 
flammation, and is sometimes distinguished from it with 
difficulty, particularly as we know that active inflamma- 
tion may occur there without frequency of pulse ; and, on 
the other hand, that there may be pretty acute tender- 
ness of the abdomen, from flatulent distension with- 
out inflammation. The tenderness in such cases, how- 
ever, is usually both partial and temporary, depending, 
apparently on an unusual degree of sudden flatulent dis- 
tension of part of the intestines. 

In general, the pain of Colic occurs in paroxysms, 
" circa umbilicum torquens," and is relieved by pressure. 
It is often violent, although always remittent, is attended 
with sickness, vomiting, and constipation ; sometimes 
it appears to proceed merely from the obstruction of 
long retained and indurated feeces, most frequent in 
women, — sometimes from intestinal concretions, which 
in a few cases can be felt externally ; — sometimes from 
merely flatulent distension from improper aliments, shift^^ 
ing its place, and also capable of being felt ; not unfre- 
quently it appears to be a form of Neuralgia, not re- 
ferable to any of these causes. The most intractable 
cases are those which proceed from the poison of Lead 
(chiefly if not exclusively the carbonate of lead), somehow 
introduced into the body. This Colica Pictonum is 
usually associated, after a time, with partial palsy of 
some of the limbs, and wasting, especially of the ex- 
terior muscles ; and ample observation has shewn that 
colic from this cause may last long, and cause extreme 



CHRONIC DISEASES OF THE INTESTINES. 615 



suffering, and leave beliind it no mark of disease in tlie 
abdomen perceptible in dissection.^ 

It has been lately stated tbat the action of lead on the 
system may be known by a bluish line along the edge of 
the gums, next the teeth, which, if fully confirmed, will 
be a useful guide. 

It is also to be remembered that pains hardly to be 
distinguished from those of colic may be the eJQPect of 
urinary calculi, impacted in the pelvis of the kidney or 
in the ureter. 

"When the existence of this cause cannot be ascertained, 
the occurrence of violent colic should always lead us to 
examine carefully for indications of inflammation, or 
for Hernise, and may often justify, when there is no 
special contra-indication, the use of bloodletting while 
the nature of the disease is still obscure ; and the repeated 
recurrence of colic may always induce suspicion of some 
kind of organic disease, impeding the peristaltic action 
of the intestines; and when the disease becomes at- 
tended with gradually increasing emaciation and debility, 
we can have little doubt of this being its cause. 

.Such organic impediment to the passage of the faeces 
is often the result of adhesion of the folds of intestine 
to one another, or to adjoining organs (particularly in 
the pelvis in women), by lymph thrown out by previous 
healthy inflammation ; and this may often be suspected 
from the previous history : but in many cases it results 
from heterologous deposits, of the kinds formerly men- 
tioned, as frequently found in the stomach, and which 
occur also in various parts of the canal, especially the 

* The altered colour and appearance of the muscles paralyzed 
by lead, noticed by Hunter and others, is certainly not a uniform 
appearance, and may probably therefore, when seen, have been only 
an effect of long continued inaction » 



616 OUTLINES OF PATHOLOGY AND PRACTICE. 



great intestines ; commencing generally in the submu- 
cous cellular tissue, and varying exceedingly, from simple 
thickening and induration of that texture, causing more 
or less of Stricture, to the formation in it of scrofulous 
tubercles, of Fibro-cartilaginous or Scirrhous tumours, 
or of the Colloid, Encephaloid, or Melanotic masses. 
They generally lead, sooner or later, to ulceration of 
the mucous membrane immediately above them, and 
often to considerable distension of the alimentary canal 
above them, as compared with the part below them : 
they often attain such size as to be felt through the in- 
teguments of the abdomen ; when seated in the rectum, 
they may be felt by the finger or bougie, although there 
are sources of fallacy in regard to this last observation, 
in some cases, from the form of the Sacrum in some 
persons, and from disease, or mal-position of the Uterus 
in women, which have led to inaccurate statements. 

We must admit, that these organic diseases of the 
alimentary canal can often hardly be distinguished, 
during life, from the effects of simple chronic inflamma- 
tion. Their symptoms are of very various intensity, 
and often subject to remarkable remissions ; but the 
most frequent and important are, — pain and anxiety; 
nausea and vomiting, constipation, alternating usually 
with painful and intractable, though seldom violent, 
diarrhoea ; tenesmus, and frequently mucous and bloody 
stools, and alteration of the natural form of the feculent 
evacuations, when the disease is in the great intestines ; 
obstinate costiveness, and tympanitic distension, with 
pain, vomiting, and sometimes ileus, when it attains such 
a size as nearly to close the passage ; and progressive 
emaciation and debility in almost all cases. 

Such disease very often excites, or becomes complicated 
with, inflammation, acute or chronic, in the parts around 



CHRONIC DISEASES OF THE INTESTINES. GIT 



them, even repeatedly before it is fatal; and in con- 
sequence of the adhesions thus formed, ulceration extend- 
ing through all the coats of the stomach or bowels has 
often been found connected with organic diseases, in 
which the contents had not escaped, and the usually 
fatal effects of perforation of these coats had been averted. 
In other cases, the ulceration and adhesions have led 
to false communications between the upper and lower 
portions of the canal, making large portions of the tube 
useless, but by which life has been considerably pro- 
longed ; and in a few they have led to external abscesses 
and fistulous communications with the intestines, by 
which the faeces have been voided for a considerable 
time. 

These are very generally diseases of advanced life ; 
but one set of organs, necessarily connected with the 
functions of the bowels, the Mesenteric Glands, are 
very often organically diseased in children and young 
persons. The kind of aff'ection is the deposition and 
growth of the common scrofulous tubercles in these 
glands — sometimes as a part of a more general deposi- 
tion,— sometimes almost exclusively ; — in some in- 
stances, with symptoms, and indications on dissection, 
of chronic inflammation preceding the formation of the 
tubercles, — in others, without such indications ; — some- 
times apparently depending on the previous formation of 
ulcers on the mucous membrane of the bowels at the 
parts corresponding to the affected glands, formerly 
noticed under the head of Inflammation of the Intes- 
tines, — sometimes when little or no disease of that 
kind accompanies it. The tubercles undergo changes 
almost exactly corresponding to those in the lungs, but 
few have, in general, passed into suppuration before 
death takes place. The local symptoms are generally 



618 OUTLINES OF PATHOLOGY AND PRACTICE. 



obscure and equivocal ; tympanitic distension and mu- 
cous diarrhoea are perhaps the most common ; but the 
gradual emaciation, paleness, and weakness, in a scro- 
fulous habit, in early youth, and without adequate ap- 
parent cause, are generally sufficient to excite strong 
suspicion of the disease. In other instances, but sel- 
dom without some affection of the glands, the tubercu- 
lar deposition takes place chiefly on the peritonaeum, 
leading to the great solid enlargements, with colic pains, 
often attended with sense of heat,, and occasional diar- 
rhoea, often also with partial serous effusion, described 
by Dr Baron. The medullary sarcoma also occasionally 
affects the mesenteric glands, and peritoneum, producing 
similar symptoms, but a more rapid progress. In adults 
it is not uncommon to find cartilaginous or bony concre- 
tions {L e, hardened tubercles), or encysted tumours, in 
these glands, without any symptoms having been observed 
which can be confidently ascribed to these lesions. 

When not fatal by reason of the inflammations that 
are complicated with them, or by the colic gradually 
taking the form of Ileus, from nearly complete closing 
of the passage, these organic affections of the digestive 
organs may go on until the patient is so much weakened 
and exhausted, that his death takes place nearly in the 
same manner as that caused by fasting. 

In some constitutions, and especially in the case of j 
children, it is important" to be aware, that chronic affec- j 
tions of the bowels, especially those connected with i 
ulceration, even partial, of the mucous membrane, or 
with disease of the mesenteric glands, are very apt to * 
give origin to affections of the brain and nervous system ; 
either to strictly inflammatory affections there, ending in 
serous effusions, formerly noticed, or to different chronic 
diseases of those parts, to be considered afterwards. 



CHEONIC DISEASES OF THE INTESTINES. 619 



The different kinds of Worms, so often found in the 
alimentary canal, and the origin of which is still ob- 
scure, the small worms called Trichuris (usually found 
in the coecum), and Ascaris vermicularis (usually found 
in the rectum) ;— the long round worm (Ascaris lum- 
bricoides) which usually infests the small intestines ; 
and the jointed tape-worm or Teenia, also found there, 
but more frequently in adults, — demand attention here, 
chiefly because of the effect of the irritation which they 
occasion, to excite symptoms of nervous disorders, and 
sometimes dangerous diseases of the Nervous System. 
The symptoms which they excite in the abdomen itself, 
colic pains, capricious appetite, tympanitic abdomen, 
and troublesome itching at the anus, and especially at 
the nostrils, cannot be distinguished with certainty from 
those tvhich other irritations acting on the mucous 
membrane, or slight inflammation and ulceration, may 
occasion there ; but from the action of the lumbrici in 
particular, epileptic fits, and more anomalous nervous 
affections, have often evidently originated ; and in some 
cases symptoms closely resembling those of hydrocepha- 
lus {{» e, inflammation in the brain) have been apparent- 
ly excited in this way, and abated after the expulsion 
of the worms ; while in others, the symptoms apparent- 
ly originating in this way, have gone on to decided and 
fatal hydrocephalus. 

The treatment of the merely spasmodic or flatulent 
colic, consists simply in the combination or alternation 
of laxatives with anodynes, especially opiates. Some- 
times a full dose of castor oil alone, or with laudanum 
or morphia, procures both full evacuation and complete 
relief ; but frequently, and particularly when the dis- 



620 OUTLINES OF PATHOLOGY AND PRACTICE. 



ease is of some standing, it is better to give an opiate 
first, and afterwards sueli a combination of laxatives 
and enemata, or enemata followed by laxatives, in re- 
peated ratber tban in very large doses, as may cause 
full evacuation. When the case is merely of this kind, 
stimulants and carminatives, probably by restraining the 
sudden distension of the bowels, give much relief ; and 
therefore mixtures containing some of the purgative 
tinctures answer well. There is no indication for mer- 
curial medicines in such cases, at least none for affec- 
tion of the system by them ; and their use may, in 
some constitutions, rather alter or prolong, than re- 
lieve the disease ; and the remedies now mentioned 
(often repeated), with hot fomentations, and the warm 
bath, are all that can be required. In some cases, par- 
ticularly in women, such accumulations of hardened 
feeces are brought to the rectum, as require not only 
enemata, but mechanical means of breaking them down, 
before they can be thoroughly evacuated. 

In cases of habitual constipation with colic pains, 
from errors in diet, and neglected bowels, it usually hap- 
pens that, after strong purgatives have been used, and 
accumulations removed, the milder laxatives are effec- 
tual, and, with a somewhat laxative diet, comprising 
vegetable matters, well boiled or otherwise prepared, | 
will answer every purpose. But when the pains are of 
simply neuralgic character, returning in paroxysms, in- 
fluenced by the weather, and unconnected with any as- 
certained torpor or derangement of the action of the | 
bowels, these remedies will prove unavailing, and al- | 
though the alternation of laxatives and anodynes is still 
required, they must be regarded as palliatives only ; 
eac.h paroxysm of the disease will gradually and spon- 



CHRONIC DISEASES OF THE INTESTINES. 621 



taneously subside ; or it may be permanently relieved 
(altbougb not uniformly or certainly) by Quinine or 
preparations of Steel. 

If the action of tbe poison of lead can be ascertained, 
tbe same general plan of treatment is required, and 
must often be very frequently repeated ; but if tbere is 
reason to think that any part of the lead remains in the 
Primee Vise, there is a special indication for the laxa- 
tive Sulphates (of Soda or Magnesia) to form the in- 
soluble and inert Sulphate of Lead. And it has been 
lately stated, with great probability, that the free use 
of drinks containing Sulphuric Acid, is an effectual 
preservative against the disease, even for workmen and 
others, who are unavoidably exposed to its cause.* 

In cases where, from the obstinate recurrence of the 
symptoms, from the weakness and emaciation attending 
them, or from more special evidence, we are pretty cer- 
tain of the existence of organic disease, more or less 
impeding the action of the bowels, the most important 
practical rule is similar to that insisted on as to inflamma- 
tion, with similar complications, — that purgatives by 
the mouth be used sparingly and cautiously, lest, by 
forcing the contents of the bowels against constricted or 
compressed portions of the intestine, they increase the 
sufferings of the patient, and probably irritate the af- 
flicted part into inflammation and ulceration. Some 
cases of this kind are ascertained to depend on stricture 
of the rectum, and admit of relief, at least in the early 
stages, from its dilatation by the bougie. 

There are a few cases of this description in which the 
bowels have been long constipated, f where, under the in- 

* See Watson's Lectures, vol. ii. p. 455. 

■f In one case, under mj own observation, for twenty-five days,* 



622 OUTLINES OF PATHOLOGY AND PKACTICE. 



fluence of mercury, affecting the mouth, the natural 
action of the intestines has been restored ; and therefore, 
in cases where highly scrofulous or malignant constitu- 
tional disease is not indicated, this expedient may be 
tried. In some cases the external application of purga- 
tive medicines, in liniments or poultices, has seemed 
effectual when their internal use was ineffectual or in- 
jurious ; and in others, Galvanism, applied gently but 
continuously, has seemed to remove the obstruction ; but 
in general the case is to be regarded as hopeless, and 
the object of the practitioner should be to procure eva- 
cuations, as long as it can be done, by mild medicines 
and enemata, and, at all events, to mitigate pain and 
spasmodic action by repeated and full doses of Opium 
or other anodynes ; watching at the same time for occa- 
sional inflammatory attacks, which, even at an advanced 
period of the disease, may be properly obviated by anti- 
phlogistic remedies, with much relief to suffering, al- 
though at the risk of a somewhat earlier exhaustion of 
strength. 

The expulsion of worms from the intestines is to be 
effected, partly by repeated doses of purgatives, particu- 
larly the resinous and mercurial Cathartics, and partly 
by the use of medicines, and in the case of the Ascarides 
of Enemata, which act on them as poisons, — of which 
the best recommended are, for the Teemia, the Oil of 
Turpentine (often given along with Castor-oil),- — or 
the Decoction of the Pomegranate ; — for the Lumbrici, 
the Oil of Turpentine with Castor-oil, and different bit- 
ters and Chalybeates, likewise the Tin-filings ; — for the 
Ascarides, the Bitter infusions. Lime-water, a strong 
Solution of common Salt, or the Tinctura muriatis 
Ferri largely diluted — given in enema. 



ABDOMINAL DROPSY. 



623 



III. The Ascites, or Abdominal Dropsy, i. e, the 
Serous Effusion into the cavity of the abdomen, is 
easily recognised by the peculiar feeling of fluctuation, 
and most commonly depends, not only on the general 
causes of dropsy already mentioned, but on some special 
causes of determination to, or congestion in, the dif- 
ferent parts of the Peritoneum. Of these, by far the 
most common is such disease of the Liver, generally 
induration (often with enlargement, but sometimes with 
diminution of size), as obstructs the free flow of blood 
through the Vena Portse. But in other cases, particu- 
larly in young persons, the Ascites is connected either with 
the chronic forms of inflammation, or with tubercular 
or other morbid deposits on the Peritoneum and in the 
mesenteric glands. In such cases, disease of the kid- 
neys is likewise often present. And there are other 
cases of this effusion, which seem to be connected, or 
to alternate, with the increased flow from the mucous 
membrane of the intestines, constituting the Diarrhoea 
Mucosa, even when the liver is sound. 

Cases of Ascites, therefore, are sometimes attended 
with such indications of inflammatory action, as de- 
mand evacuation— at least local — of blood ; and when 
this is the case, the subsequent action of the laxatives 
and diuretics is sometimes remarkably increased : but 
more frequently the diseases which determine this form 
of serous effusion, are quite chronic ; and it is an im- 
portant practical observation, that Ascites is less fre- 
quently removed by remedies than Anasarca, or even 
Hydrothorax, probably because the causes which lead 
to effusion at this part are more permanent. Accord- 
ingly, this form of dropsy is generally observed to be 
attended with more indications of feeble health, parti- 

I 



624 OUTLINES OF PATHOLOGY AND PRACTICE. 



cularly of deficient digestion or assimilation of food, 
than attend tlie hydrotliorax. 

There is, therefore, more generally an indication in 
this than in other dropsies, for the nse of deobstruents, 
such as Mercury or Iodine, along with the means of 
remoyiug the effusion, already considered ; but in a large 
proportion of cases, the use of them is clearly contra- 
indicated by the enfeebled state of the patient, and by 
their known inefficacy in organic disease of any consi- 
derable extent or duration. 

The Paracentesis Abdominis has certainly in some cases 
been followed by an increased efficacy of the diuretics, 
and complete removal of the Ascites; but in a far 
greater number of cases, the relief given by it has been 
only partial, and obtained at some risk of peritoneal in- 
flammation, a slight degree of which, in feeble "habits, 
may be fatal ; and therefore, it is generally thought 
right to reserve this remedy for cases where " the extent 
of the effusion is such as to cause much suffering, par- 
ticularly by pressing on the diaphragm and impeding 
respiration. 

All that need be said in reg-ard to the Ascites Sacca- 
tus or Encysted Dropsy in the abdomen is, that the 
fact of the fluid being so confined may be in general 
detected by careful examination, particularly in the 
early stages of the disease ; that such encysted dropsies 
are occasionally found in connection with the liver 
or kidneys, particularly when they contain Hyda- 
tids ; and in that case inflammation, adhesion, ulcera- 
tion, and escape of the contents of the sac, through 
the integuments or thi^ough the lungs, may occur, as 
in cases of chronic abscesses of the same parts; but 
that their most common origin is from disease of the 



EPIDEMIC CHOLEKA. 



625 



Ovaria ; that when such disease has prockiced great 
effusion, it is very seldom capable of being affected 
by any deobstruent remedies, and the effusion in this 
situation is hardly under the influence either of purga- 
tives or diuretics ; but, on the other hand, that the para- 
centesis, as a palliative remedy, is safer in this case than 
in the Ascites Abdominalis, and has often been very 
frequently repeated. In the case of encysted dropsy 
with hydatids, the cyst is generally to be regarded as 
the largest, or parent, hydatid ; and on its being punc- 
tured, it would appear that sometimes it perishes, and its 
contents become liable to absorption, so that the whole 
disease may nearly disappear. The question as to the 
safety or expediency of the excision of diseased Ovaria 
is still sub judice, and is more properly discussed in 
surgical works. 

IV. In connexion with the disordered states of the 
Secretions and actions of the Alimentary Canal, and 
likewise in connexion with what is next to be stated, as 
to diseases depending on a morbid condition of the 
blood, a few words may be said of the pathology of the 
new and anomalous disease, which is essentially charac- 
terized by a very diseased condition of all these, viz. the 
Epidemic Cholera. 

As occurring in India, this disease was characterized 
by copious vomiting and purging of a watery fluid (often 
loaded with flakes of whitish matter), without bile ; — 
by cramps, not merely of the legs, but often pretty ge- 
neral over the body, — and by rapid sinking of the heart's 
action, — uncommon shrinking or shrivelling, coldness, 
and often blueness of the surface, — and frequently labo- 



626 



OUTLINES OF PATHOLOGY AND PRACTICE. 



rious breathing in the latter stages, as in other cases of 
death by syncope. The blood was always observed to 
lose its power of coagulation, and to be thick and dark- 
coloured, very soon after the attack of the disease. All 
the secretions, excepting those by the mucous membranes 
and the skin, appeared to be nearly suppressed during 
the violence of the disease ; but the whole duration, 
whether in fatal or favourable cases, was seldom more 
than two or three days. In this climate, there is this 
essential difference from the usual form in India, that, 
in many cases, after the symptoms above mentioned 
have abated, the system rallies, and the pulse becomes 
pretty full and firm, a state of fever, more or less dis- 
tinctly marked, often with delirium, and always with 
strong tendency to Coma, supervenes, and may be fatal 
strictly in the way of coma, at the end of some days, or 
even a fortnight or more from the attack. During this 
febrile or comatose state, although the secretion of bile 
(of morbid quality) is generally restored, that of urine 
is still frequently suppressed ; or, if passed, it is generally 
in small quantity, of low specific gravity, and often al- 
buminous. 

Botli in the warmer and colder climates, it has been 
distinctly perceived that the spasms of the limbs are not 
merely the effect of frequent stools, — not only because 
they are more general than those of the common cholera, 
but because they have often been violent before there 
was any diarrhoea, and continued after that was stopped, 
even after apparent death ; — again, that the depression 
of the heart's action is not merely the effect of the eva- 
cuations, because it is rapid and excessive in some cases 
where these are slight ; — and lastly, that the coldness of 



EPIDEMIC CHOLERA. 



627 



the surface is not merely the effect of the depression 
of the heart's action, because the body has often become 
warm immediately before, or even after death. 

The most important additional facts which have been 
lately ascertained in regard to the changes in the Epi- 
demic Cholera are, that the blood, deprived of much of 
its watery constituents by the diarrhoea, is found to con- 
tain much less water, and less ''of its usual saline ingre- 
dients, than in health ; that the watery dejections con- 
sist merely of the serosity of the blood, with a small 
quantity of albumen ; and that in the cases of long-con- 
tinued suppression of urine, the urea has been detected, 
as in cases of diseased kidneys, in the blood, and also in 
the serum of the shut cavities of the body. 

No morbid structure has been ascertained to be con- 
stantly present in the bodies of persons who have died 
of this disease. A great variety of morbid appearances, 
found in such bodies, have evidently existed before the 
attack of cholera ; others, such as softness of the mucous 
membrane of the primse via3, and unusual development 
of the mucous glands there, may reasonably be ascribed 
to the obviously great change in the distribution of the 
blood. Slight bloody effusions, or ecchymosis, often 
found on the heart, but more especially on the sympa- 
thetic nerves and par vagum, although not essential to 
the disease, and probably to be regarded as its effects, 
appear to be important as affording an explanation of 
a part of the symptoms. 

The mode of diffusion of this disease is as anomalous 
as its symptoms. Although a few cases of violent di- 
arrhoea or cholera (especially such as might be traced to 
I the action of poisonous articles of diet), have shewn 
I symptoms nearly approaching to those of this epidemic 



628 OUTLINES OF PATHOLOGY AND PRACTICE. 



disease, yet it is certain that no such disease was fre- 
quently seen, — still less did any such prevail epidemi- 
cally, — in any part of the i^^orld before 1817, — or in 
Europe before 1829, or in Britain before 1831 ; — and that 
at this day no such disease has been seen in many towns, 
villages, or districts of this country, while in others, 
during the years 1831-2, and a part of 1833, it was very 
destructive. It is quite in vain, therefore, to attempt to 
refer the appearriuce and extension of this disease to the 
agency of any of those causes of disease, which are of 
general and nearly uniform operation in any climate ; 
notwithstanding that such causes ma;y very often have 
appeared, as in the case of other epidemic diseases, to 
co-operate in exciting the disease in individuals. As 
this disease has hitherto existed only within certain as- 
signable limits of space and time, so its main cause must 
be one of local and temporary agency. 

It is equally certain, that this disease does not present 
the usual indications of one which arises from a Malaria ; 
for, instead of being confined to certain districts, and 
those of similar character in different parts of the 
world, — and of appearing and disappearing at certain 
seasons or in certain circumstauces only, — it has been 
found to prevail epidemically in all climates and all sea- 
sons, and although perhaps most frequently in low 
moist situations, yet repeatedly in all descriptions of 
localities. 

It may be stated farther, with confidence, that on 
difPerent occasions, and particularly on several occasions 
in Scotland, where the introduction of the disease into a 
town or district previously uu affected, from a known 
source {i. by a person coming from a place where the 
disease prevailed, and falling ill of it in another, pre- 



CHRONIC DISEASES OF THE INTESTINES. 629 



vioiisly untouched by it), has been carefully watched, — 
it has been observed, that those who had intercourse 
with the sick took the disease, in the first instance, in 
a proportion so very much greater than those who avoid- 
ed such intercourse, as to leave no reasonable ground for 
doubt, that it possesses a certain degree of Contagious 
property.* 

It is no objection to the belief of the contagious 
nature of the disease, that a large proportion of those 
who have free intercourse with the sick remain unaffect- 
ed ; for, where the disease is epidemic, such persons are 
necessarily exposed to the local and temporary cause of 
the disease, whatever it be ; and, therefore, their exemp- 
tion, although it proves the agency of that local cause to 
be very irregular (or contingent on conditions not yet 
understood), gives no information as to the nature or 
origin of that cause. 

But, while a certain degree of contagious property is 
confidently attributed to the disease, it must at the same 
time be stated, that, when it has become epidemic in 
towns or districts, many persons have been observed to 
be attacked, who had certainly no intercourse with the 
sick ; many others, whose intercourse either with the 
sick or with any thing that could have been in contact 
with them, must have been very slight and transient ; 
1 and sometimes it has not appeared that those who had 
i full and free intercourse with the sick, were affected in 
larger proportion than either of the two first-mentioned 
classes of persons. 

From these facts it appears to be a perfectly fair infe- 
rence, that either the disease, besides the degree of con- 
: tagious property already ascertained to belong to it, has 

* See Simpson in Edin, Med, Surg, Journal, vol. 49. 
; PART III. S S 



630 OUTLINES OF PATHOLOGY AND PEACTICE. 



another mode of extending itself, independent of con- 
tagion, and not yet understood ; or else, tliat tlie con- 
tagious poison arising from those affected with it, acts 
according to laws materially difiPerent from those which 
regulate the diffusion of other contagious diseases. It 
must have the power of extending itself to a very consi- 
derable distance through the atmosphere, so as to affect 
those who are peculiarly liable to its influence ; and, 
again, its action, even on those the most fully exposed to 
it, must be very much dependent on other circumstances 
in their situation. Its effect must bear no proportion to 
the quantity of it introduced into the system ; and its 
virulence must be liable to great and unaccountable va- 
riations at different times. 

Perhaps, when the whole history of the disease, — its 
recent introduction into the world, and its generally fol- 
lowing the great lines of human intercourse, — are taken 
into account, and the analogy of other contagious diseases 
considered, it will appear more reasonable to ascribe these 
singular properties to a specific poison of human origin, 
than to admit two distinct causes for the extensive dif- 
fusion of the disease. The old notion of the dependence 
of this and other epidemics on swarms of insects, or 
rather of animalculse, thrown off from the bodies of 
affected persons, but afterwards maintaining, for a time, 
an independent existence, agrees better with many of 
the facts observed, than any other theory that has been 
proposed.* 

Two important facts, in regard to the local and tem- 
porary cause of the disease (whatever be its nature), 

* See Holland On the Hypothesis of Insect Life as a Cause of 
Disease," in Medical Notes and Keflections. 



CHRONIC DISEASES OF THE INTESTINES. 631 



seem well ascertained, and similar in kind to wliat has 
been observed as to other epidemics, viz. 1. That its 
effect on the persons exposed to it is sometimes very- 
rapid, and sometimes delayed for several weeks ; and, 2. 
That the effect of its application is very dependent, not 
only on previons predisposition, but on subsequent con- 
tingencies j avoiding which may probably, in many cases, 
suffice to avert the disease. 

The concurrent and accessory causes which seem most 
efficient in determining attacks of the disease are, pre- 
vious organic diseases, unconnected with febrile excite- 
ment (for phthisical and other patients, with hectic 
fever, seem very little susceptible of it), intemperance, 
and previous diarrhoea. 

As the whole history of the disease shews its depen- 
dence on a local and temporary cause, so its essential 
symptoms, and the mode of its fatal termination, evi- 
dently assimilate it to the effect of Poisons on the ani- 
mal economy, much more than to the phenomena of any 
of those diseases which arise from causes of more uni- 
form occurrence. 

In particular, the spasms of voluntary muscles, and 
the very rapid depression of the heart's action, — certainly 
not referable merely to the amount of evacuation from 
the primse vise, — bear a close resemblance to the action 
of certain poisons, and to other malignant epidemic dis- 
eases proceeding from malaria or from contagion, e. g. 
yellow fever and plague. And the analogy to other 
effects of specific or morbific poisons appears farther from 
the remarkable tendency to reaction of the heart, to 
a certain degree of febrile action, and spontaneous 
favourable termination, observed in many cases of the 
disease, and under all possible variety of treatment. 



632 OUTLINES OF PATHOLOGY AND PRACTICE. 



The remarkable effect of injection of large quantities 
of weak saline solutions into tlie veins, in causing tem- 
porary excitement of the heart in the stage of collapse 
or extreme depression in this disease, shews that a part 
of the cause of the depressed state of the circulation lies 
in the altered condition of the blood consequent on the 
evacuations ; but the tendency to syncope is seen too 
early, and recurs too frequently and too rapidly, after 
the full amount of water and salts have been restored, 
to be solely referable to this cause. 

The stupor in the later stage of the disease may cer- 
tainly be ascribed, in a great measure, to the suppression 
of the excretions, particularly of the urine ; but it is still 
doubtful whether this may not be in part also a direct 
effect of the morbific poison. 

The numerous observations made in this country were 
sufficient to prove, that no known remedies, not even the 
saline injections, have any specific power of counteract- 
ing the peculiar agency of the specific poison ; and the 
cases in which the full effect of the poison, in the cir- 
culation, took place within a very short time from the 
invasion of the disease, were almost uniformly fatal. 
Hardly any of these cases, of sudden collapse, shewed 
any favourable reaction after the loss of blood, and many 
were evidently farther depressed by it ; but cases which 
began with pain, and cramps, and with firm pulse, often 
improved rapidly after bloodletting, followed imme- 
diately by full doses of opium with calomeL Cases ap- 
parently commencing with diarrhoea, and defect of bile 
in the stools, seemed to be sometimes arrested by full 
doses of opiates only ; and many cases, in which a con-^ 
siderable degree of collapse had taken place, especially 
of young persons, recovered under stimuli, internal and 



CHRONIC DISEASES OF ASSIMILATION. 633 



external, of whicli the saline injections appeared un- 
doubtedly the most powerful, — and of opium in mode- 
rate doses (regard being had to the comatose tendency 
always to be apprehended in the latter stage), with 
astringents, or with mercury. Wine or spirits could 
seldom be taken, or retained, in such quantity as to 
have a decided effect. 

The speedy removal of the unaffected inmates of the 
first houses in which the disease had shewn itself, to 
quarantine houses, or to any more airy situations, where 
they could be preserved from all accessory causes, — 
seemed to be a measure of real and important efficacy, 
in restraining the diffusion of the disease. 

Sect. V. — Of Chronic Diseases of the Function of 
Assimilation. 

We here consider several diseases, in which it is cer- 
tain that the assimilation of the aliments and constitu- 
tion of the Blood, and thereby the nature of the deposi- 
tions and excretions from the blood, are much altered, 
but of the exact seat of which (if indeed they have any 
local habitation), and of the nature of the alteration 
of the vital affinities producing them, we are still igno- 
rant. 

It is important to observe, in regard to these diseases, 
in which the constitution of the whole blood is certainly 
in fault, that the indications of their existence are often 
quite local, e. g. those of Scurvy affecting only certain 
portions of the skin and mucous membranes. These, 
therefore, clearly connect themselves with the whole of 
the constitutional organic diseases (e, g. Scurvy or Pur- 



634 OUTLINES OF PATHOLOGY AND PRACTICE, 

piira, with Melanosis), as they do also with the specific 
inflammations, and the contagious febrile diseases, and 
with the eflPects of various poisons, — and the pathology of 
all may be said to be essentially humoral. 

These chronic diseases have usually been termed Ca- 
chexias, and possess a peculiar interest and importance at 
present, because the recent discoveries in organic chemis- 
try and in microscopical anatomy give reason to hope that 
they may soon be better understood, or referred to more 
general principles than can at present be laid down, and 
that the respective provinces of chemical affinities and 
vital powers in producing them may be more clearly 
fidened. In the mean time it is certain, that, in specu- 
lating on these diseases, we must always have in view, 
not merely the chemical composition of the blood, but its 
whole constitution^ including its aptitude or inaptitude 
for certain changes which are constantly going on in it, 
but which are essentially vital phenomena, and may be 
referred, in general terms, to vital affinities. 

The principle laid down by Liebig, if fully confirmed, 
viz. that the food of man consists of two parts, — the 
non-azotized portion^ which is destined only to unite with 
the oxygen of the air, and maintain the excretions and 
thereby the heat of the body, and the azotized portion^ 
or compounds of Proteine, which go to the maintenance 
of the organized structures, — will be a leading principle 
in the pathology of these diseases ; but in order to enable 
us to turn this general law, supposing it established, to 
practical account, we must first understand how far the 
different excretions are supplied by those non-azotized 
ingesta ; how far by the azotized articles of food, parti- 
cularly if in excess ; and how far by the disintegration 
of the textures already existing in the body, and continu- 



CHRONIC DISEASES OF ASSIMILATION. 635 



ally liable to absorption.* This seems to be tbe great- 
est difficulty at present attending ^tlie investigation of 
tliese diseases. 

I. The symptoms of Scorbutus or Scurvy are exactly 
the same, and indicate the same kind of alteration in the 
constitution of the blood as those of Purpura, already 
considered, in connection with cutaneous diseases, i. e, 
not only purple spots and ecchymoses (often very exten- 
sive), spungy gums, haemorrhages, particularly at injured 
or inflamed parts ; but farther, great emaciation, ab- 
sorption even of the callus uniting broken bones, de- 
bility, faintness, and ultimately death by Asthenia ; but 
with this remarkable difference, that the former are dis- 
tinctly produced by deficient or unwholesome aliments, 
and by other causes which depress vital action, and are 
injured by any causes which have a weakening effect ; 
whereas the latter take place independently of the action 
of any such cause, are often co-existent with inflamma- 
tory as well as febrile diseases, and even appear dis- 
tinctly to be sometimes excited by the invasion of such 
diseases ; and are relieved rather than aggravated by 
such depleting remedies as may be effectual in subdu- 
ing these concomitant affections. The Purpura, there- 
fore, would seem to consist entirely in a perversion of 
the vital process of assimilation ; whereas the Scurvy is 
probably always chiefly owing to a defective state of 
the materials, on which that process is performed. 

Like the Purpura, the Scurvy is apt to combine itself 
with others, particularly inflammatory diseases, and then 

* See Review of Dr Bence Jones on Calculous Disorders, in Bri- 
tish and Foreign Medical Review, 1843. 



636 OUTLINES OF PATHOLOGY AND PRACTICE 



the effusions from these inflammations are tinged with, 
or even consist of, entire blood. This seems to have been 
exemplified in fatal cases of scurvy with effusions be- 
neath the Periosteum, given by Dr Budd (Library of 
Pract. Medicine, vol. 5), also with effusion in the Peri- 
cardium, described by Dr Seidlitz in Russia (British 
and Foreign Review, vol. i.) 

Extensive and long-continued as has been the expe- 
rience of the production and effects of Scurvy, there has 
been much difficulty in fixing on the particular altera- 
tions in the constitution of the blood in which it consists, 
and on the particular causes which are necessary to 
its development and increase. It has been generally 
supposed, that the red globules are broken down and dif- 
fused through the serum, and that the coagulation of 
the blood is imperfect, implying defect in the quantity 
or vital properties of the fibrin ; and it is certain that 
in some cases both these peculiarities in the state of the 
blood have been observed nor does it seem easy to con- 
ceive, how the extravasations of blood, characteristic of 
scurvy, can take place, while the fibrin and the globules 
retain their usual qualities. But in other instances, 
the separation of crassamentum and serum, and the firm 
coagulation of the fibrin of the former, have been ob- 
served equally in the blood of persons affected with 
scurvy (perhaps complicated with inflammation), as in 
healthy blood.f Similar varieties have been observed, 
even during the progress of the same case, in Purpura. 

* See e. g, Dr Watson's account of the blood drawn from a pa- 
tient of his. Lectures, vol. ii. p. 804, and Huxham, quoted by him. 

t See Article Scurvy by Dr Eudd, in Tweedie's Library of Medi- 
cine, vol. V. p. 191. 



CHKONIC DISEASES OF ASSIMILATION. 



637 



The proportion of the globules to the other constituents 
of the blood appeared,- in the cases now quoted, to have 
been much diminished ; but that is a change common to 
this and various other chronic and weakening di?3eases, 
particularly Chlorosis, and disease of the kidneys. 

The researches of Dr Budd, and his collection of very 
numerous prior observations, seem to have nearly estab- 
lished, that the scurvy neither depends on the use of salt- 
ed provisions, as has been commonly thought, nor on de- 
ficiency of nourishing food, as some have supposed, but 
exclusively on the long-continued absence of certain kinds 
of vegetable food ; and that the true anti-scorbutics are 
the vegetable acids, as lime-juice and lemon-juice, and the 
succulent vegetables, especially if taken raw, or in a state 
of, or prone to pass into, acetous fermentation, not when 
much acted on by heat. Potatoes appear, from the ob- 
servations of Dr Baly, to be distinctly anti-scorbutic, 
probably from containing much vegetable acid ; * but 
the farinaceous vegetables, and generally the vegetable 
albumen and gluten, have no such virtue. 

It would here seem pretty clearly indicated, that the 
introduction of non-azotised aliments is necessary for 
the prevention and cure of scurvy ; and according to 
the principles of Liebig, this may be supposed owing to 
their supplying carbon and hydrogen to the oxygen of 
the air, and thereby protecting the animal solids, and 
probably the fibrin and globules of the blood, from the 
destructive agency of the oxygen. 

It is very doubtful, however, whether this would ex- 
plain the peculiar virtue of the vegetable acids, in 
counteracting the tendency to scurvy ; and at all events, 
that the change in the constitution of the blood, which 
* See Watson, I. c. p. 600. 



638 OUTLINES OF PATHOLOGY AND PRACTICE. 



occurs in scurvy, is influenced by causes exclusively vital, 
is certain not only from the fact, tliat a similar change 
on the constitution of the blood takes place in the Pur- 
pura, where no chemical cause for it exists ; but also, 
from the observed effects of all causes which weaken 
vital action, particularly cold, inactivity, and depressing- 
passions of mind (perhaps diminishing the force of vital 
affinity, by which the usual condition of the fibrin and 
globules during life is determined), in disposing to the 
disease.* 

The rapid eflPect of fresh succulent vegetables, and 
vegetable acids, on the whole symptoms of Scurvy, and 
therefore on the constitution of the blood in that disease, 
is more striking than that of any other remedy, on a 
chronic disease. All other remedies, stimulants, tonics, 
astringents, &c. are trifling in comparison ; but it has 
been repeatedly stated, and particularly very lately, that 
frequent doses of Nitrate of Potass possess a similar 
virtue. 

II. The tendency to dry Gangrene of the extremities, 
i. e. to death of various superficial parts of the body, 
preceded by pains of those parts, but very little of the 
other symptoms of inflammation, and attended with 
hardly any fluid effusions, is another case of disease 
afi'ecting individual organs only, but clearly dependent 
on a diseased condition of the blood, resulting from ali- 

* A remarkable instance of the power of such mental causes is 
given in an account of the extension of scurvy among a class of 
convicts, by Dr M'Cormac, transported on account of agrarian dis- 
turbances, when the crew of the ship, and other convicts, habitual 
felons, were unaffected.— ilfef/iocZii^ Medendi, p. 213. 



CHRONIC DISEASES OF ASSIMILATION. 639 



meiits which are in a certain degree poisonous, or not 
duly assimilated; it being fully ascertained that this 
disease has been occasionally endemic in different coun- 
tries, only because damaged grain, and especially rye, 
infected with the ergot (Secale cornutum), has formed 
a large part of the nourishment of the people. The ex- 
periments which prove that a similar disease is produced 
in animals fed with this grain, and the disappearance of 
the disease when sound grain only has been used, are 
conclusive on this point. 

III. Another disease, which is properly regarded as 
depending on a morbid condition of the function of as- 
similation, and of the constitution of the blood, is the 
Rachitis, — of which the characteristic symptoms result 
from the peculiar nutrition and softened state of the 
bones— the large head, with projection of the frontal 
bone, enlargement of the joints, depression of the cen- 
tral parts of the ribs, and, when the erect posture is 
habitually assumed, the curvature of the bones of the 
extremities. But it is equally certain, that all the solids 
of the body are imperfectly nourished, and the muscular 
parts in particular are soft, flabby, and feeble, the muscular 
fibres of the intestines relaxed, and abdomen tympanitic; 
while the almost uniform precocity of intellect shews 
that the nervous matter in the brain must be in a state 
of morbid activity. The bones, in this disease, are not 
only deficient in earthy matter, but do not acquire their 
usual structure ; their cellular texture is less compact 
than natural, the contents of the cells gelatinous instead 
of being medullary ; and, while the extremities of the 
long bones acquire an unnatural size, the medullary 
canals are not formed in the usual way in their in- 
terior. 



640 OUTLINES OF PATHOLOGY AND PEACTICE. 

This is a disease of infancy and cMdhood ; the 
causes of which are apparently the same as those for- 
merly stated as favouring the scrofulous diathesis, — 
damp and impure air, want of exercise, innutritions 
diet, or such disorders of the stomach and bowels as 
habitually impair the digestion and assimilation of food ; 
and it occurs so frequently in the children of scrofulous 
parents, and is so continually associated with scrofulous 
disease, that we can have no difficulty in regarding it as 
dependent on a constitution of the blood essentially 
similar. 

It is certain, that this disease may be produced, al- 
together independently of any want of the usual earthy 
salts in the ingesta, and that it cannot be remedied by 
merely adding phosphate and carbonate of lime to the 
food; and it is certain also, that it is often attended 
with an unusual excretion of the phosphates, by the 
bowels or kidneys, or both ; and that in other cases 
there is an irregular deposition of phosphate of lime,* 
shewing that the quantity of this substance in the sys- 
tem is not deficient, but that the fault lies in the vital 
powers and affinities by which the nutrition of bones 
and other textures is effected ; but these observations 
leave it still doubtful, whether the blood, in rickety 
patients, contains the phosphates in an unusual state, or 
whether there is in the bones a defect in the vital power 
of abstracting it from the blood, or in the blood an ex- 
cess of the power of abstracting or reabsorbing it from 
the bones. 

But whatever be the precise nature of the change in 
the vital acts, subservient to the nutrition of the bones. 



* See Wilson on the Bones and Joints, p. 164. 



CHKONIC DISEASES OF ASSIMILATION. 



641 



muscles, and nervous matter, in tins disease, it is certain, 
that it is in a very considerable degree under tlie control of 
causes wliich can only affect vital action ; for by the con- 
tinued use of a Tonic Regimen, by solid and nutritious 
diet, pure and dry air, habitual inducement to muscular 
exertion, by tepid or cold bathing, and assiduous fric- 
tions, and by the use of medicines which promote the 
appetite and digestion, particularly of the preparations 
of steel, many children affected with rickets, are gra- 
dually restored to health ; and the only other medicines 
which appear useful, are such as are fitted to obviate 
symptoms of derangement of the stomach and bowels, 
as they appear, — the ant-acids, the bitters, the mild 
laxatives, or astringents with opium, according to the 
state of the bowels. 

It is to be observed, that the alteration of the form 
of the chest, which takes place in this disease, renders 
the breathing somewhat short, or easily embarrassed, 
and, in many cases, disposes to Bronchitis, or more urgent 
diseases of the chest, the symptoms of which necessarily 
interrupt the use of the tonic regimen, and even de- 
mand, in many cases, that the antiphlogistic regimen 
and remedies, in so far as the patient's strength appears 
fitted to bear them, should be substituted. 

IV. Another case, in which the constitution of the 
blood is undoubtedly altered, by a very peculiar perver- 
sion of the function of assimilation, is that of Diabetes. 

There are, however, two distinct diseases to which 
this name is given, although their pathology is widely 
different; the D. insipidus, in which the quantity of 
urine is greatly increased, but its specific gravity pro- 
portionally diminished; and the D. mellitus, in which 



642 



OUTLINES OF PATHOLOGY AND PRACTICE. 



the urine is not only in greater quantity but of higlier 
specific gravity than natural (its specific gravity 1035 
to 1045, instead of 1020 to 1025), and usually loaded 
with sugar. 

In the former case there is always much thirst, and 
the urine seems in exact proportion to the quantity of 
fluid taken into the blood, so that the essential part of 
the case maybe called Polydipsia, or it maybe thought 
only a modification of Dyspepsia., although, from being 
of very long duration, attended with emaciation, and 
very little influenced by remedies, it is of more formida- 
ble character. 

In the latter cases, there is not only great thirst, but 
morbid appetite ; but the quantity of urine is so great, 
often from 20 to 30, and sometimes above 40 lb. in 
the day, and its specific gravity so high, that fully 
twenty times the usual quantity of solid matter may pass 
off by the kidneys, and with it frequently much more 
fluid than is taken in ; so that, notwithstanding the great 
quantity of ingesta, a gradual diminution of the weight 
of the body usually attends the disease. Along with 
this, there is usually, at first, a remarkable dryness of 
the skin, gradually increasing debility, and bodily and 
mental torpor. In the advanced stages of the disease 
there is some degree of fever, and often much sweating, 
and some patients die by mere exhaustion or anoemia, 
while a greater number die from the effect of some 
more acute, often inflammatory disease, which super- 
venes in the enfeebled state of the body. 

It is quite certain that the disease is not only consti- 
tutional but often hereditary, but the causes which di- 
rectly excite it, seem to be the same as produce in other 
persons very different diseases, particularly exposure to 



CHRONIC DISEASES OF ASSIMILATION, 643 



cold or wet, and mental depression. In many cases no 
exciting cause is observed. 

The presence of sugar in the urine is not essential to 
the development of the disease, for the same symptoms 
have been observed in a few cases where the urine was 
in greater quantity and of greater density than natural, 
though containing only its usual constituents. It has 
even appeared in some cases, that this Diabetes Ureoms 
has gradually changed into the mellitus ; and it has been 
ascertained also, that the urea and other solids of the 
urine are not absent during the presence of the sugar, 
but exist along with it, sometimes even in larger pro- 
portion than natural. 

And it is ascertained, not only that the kidneys are 
sound in this disease, but that no perceptible organic 
lesion of any organ necessarily attends it, — that the kid- 
neys even remain fit for their usual function during it ; 
and for a short time before death, when the strength is 
very much impaired, that they secrete urine of the 
natural quantity and quality ; farther, that the sugar 
exists in the blood, and even, according to the obser- 
vations of Mr Macgregor, that it exists in the Primse 
Vise in unnatural quantity, as shewn by fermentation 
of their contents with yeast. 

The disease is therefore strictly one of the Function 
of Assimilation ; but it is still doubtful what is the ori- 
ginal and fundamental change. It may be supposed, 
that it is a morbid increase of the function of Absorp- 
tion, all over the body ; that this is indicated generally 
by the wasting of the body, notwithstanding the enor- 
mous ingesta, and more especially by the great hunger 
and thirst, by the morbid dryness of the skin, in the 
early stage, by costiveness of the bowels, and by an 



644 OUTLINES OF PATHOLOGY AND PEACTTCE. 



increased absorption at tlie lungs, shewn hj the fact, 
that the dhiiinution of Aveight of the body in a given 
time, is not nearly equal to the difference between the 
observed egesta and the observed ingesta in that time,* — 
that hence the uric acid and urea, which are formed by the 
absorption of portions of textures previously existing in 
the body, are necessarily increased ; but that the chief 
supply of this morbidly increased absorption being from 
the Primte Vise, the aliments which yield it are not 
capable of furnishing so much azotized matter, as to 
load the whole fluid which they supply with uric acid 
and urea, but furnish, in addition to these substances, 
a large quantity of sugar, a substance known to have 
this remarkable relation to urea, that it contains, in 
given weights, the same quantity of hydrogen, and twice 
as much oxygen and carbon, with no azote. 

Or it may be supposed, that the original change is the 
tendency of the fluids of the body to form sugar, a ten- 
dency which is communicated to the ingesta; that the 
sugar thus formed and taken into the blood, being greatly 
in excess of any demands of the system for that mat- 
ter, acts as a powerful diuretic, and is thrown ofi* by 
the kidneys, stimulating them to a great increase of 
watery secretion ; and then that the increased absorp- 
tion all over the body, and the hunger and thirst con- 
sequent on that increased absorption, are to be ascribed 
to the greptt evacuation, both of fluids and solids, thus 
eff'ected. 

Which of these is the more correct view cannot be 
known, until we have more precise information as to the 
modification w^hich chemical laws undergo in the eco- 

* See Dill in Edinburgh Medico-Chirurgical Transactions, vol. ii. 



CHRONIC DISEASES OF ASSIMILATION. 645 



nomy of living bodies, and as to the relation of these 
laws to the movements of the flnids in their interior. 

It is obvious that the sugar found in the blood, and 
in the urine in this disease, must be furnished chiefly by 
the vegetable portion of the ingesta ; and accordingly it 
is found, that, by the use of a diet almost exclusively 
animal, the quantity and density of the urine are con- 
siderably diminished ; and experience has farther shewn, 
that, along with this change, a considerable abatement 
of the other symptoms of the disease is often effected, — 
so far favouring the second of the theories above stated 
as to the essential nature of the disease. 

But the purely animal diet can hardly ever be taken 
for a length of time, and neither by this nor any other, 
known means is the disease permanently subdued. It 
very often abates for a considerable time, seldom is it- 
self fatal, and in a few cases has disappeared entirely ; 
but sooner or later it very generally returns, and by its 
weakening effect, disposes to the accession, and accele- 
rates the fatal effect, of other complaints, perhaps most 
frequently of the chest. 

Besides the animal diet, however, other means are 
often found to have a considerable effect in restraining 
it, particularly, 

1. In the early stage, bloodletting, even repeatedly. 

2. The warm or vapour bath, during the very dry 
state of the skin. 

3. As much exercise as the patient can be induced to 
take, or can take without exhaustion. 

4. Opiates in gradually increasing doses, which seem 
to be on the whole more generally effectual than any 
other means. 

PART III. T t 



646 OUTLINES OF PATHOLOGY AND PRACTICE, 



5. Bitters, chalybeates, acids, other astringents, creo- 
sote, ammonia, given along with the opiates. 

6. Wine and other stimulants, when the strength is 
becoming much impaired. 

The use of laxatives is requisite, more on account of 
constipation generally attending the disease than of the 
effects of the opiates during it ; but they do not seem to 
have any favourable effect on the disease itself. 

V. Another diseased state, of much importance, and 
certainly dependent on a faulty condition of the function 
of assimilation and the constitution of the blood, is the 
Inthiasis, or tendency to the deposition of Calculi from 
the urine, in the living body, which tendency may be 
advantageously considered separately from the local ef- 
fects which result from these deposits taking place in 
the urinary passages. 

That the lithiasis is dependent on the constitution of 
the blood brought to the kidneys, rather than on any 
morbid action of the kidneys themselves, has been long 
believed, from the absence of organic lesion of the kid- 
neys, in most cases of the disease, — from their observed 
connection with disorders of the stomach, and from 
the efficacy of all means which correct such disorders, 
in relieving them ; and this conclusion is strongly con- 
firmed by its being known, that the materials of the 
animal matter, as well as of the inorganic ingredients 
of this or of other excretions, exist in the blood in the 
same state, or almost exactly the same, in which they 
are separated at the kidneys. 

These observations, however, apply more strictly to 
the formation of one great class of deposits from the 



CHEONIC DISEASES OF ASSIMILATION. 



647 



urine, viz. the Lithic Acid and Lithates, and the com- 
pounds of OxaHc Acid, of which the chief ingredients 
are organic products, than of the other great class of 
urinary deposits, viz. the Phosphates, which are almost 
entirely inorganic deposits, and the formation of which 
appears, in many cases, to be promoted by injury or 
disease of the kidneys. 

The usual kinds of urinary gravel or sand are easily 
distinguished, especially the lithic acid, and lithate of 
ammonia, by their reddish colour and solubility in al- 
kalies, without or with disengagement by ammonia, — 
the phosphates by the white colour, insolubility in alka- 
lies, and solubility in muriatic acid. The gravelly de- 
posits from the urine containing Lithic acid and Lithates, 
take place under various circumstances of the body, fre- 
quently before the age of puberty, seldom during youth, 
but frequently also in more advanced life, in those who 
lead sedentary and luxurious lives, in whom they are 
very often associated with repeated fits of Gout ; and 
it was formerly stated, that the frequent concurrence of 
these diseases, and the existence of lithic acid in the de- 
posits in gouty limbs, have led to the opinion that gout 
depends essentially, and make it nearly certain that it 
must depend partly, on the existence of too much lithic 
acid in the blood. 

It has been long known that the lithic acid and the 
urea contain a larger quantity of azote than any other 
animal matters, and must, therefore, be formed from the 
albumen and fibrin of the blood, and of the textures. 

It is supposed by Liebig, that these animal constitu- 
ents of the urine are formed only by that decomposition 
of previously existing albuminous tissues, which seems 
to attend the performance of all vital actions, under the 



648 OUTLINES OF PATHOLOGY AND PEACTICE, 



influence of the oxygen taken in at the lungs ; that the 
litbic acid and lithate of ammonia (as tlie proportions 
of tlieir elements indicate) are formed by tbe lowest degree 
of oxidation of tbe product of that decomposition, tbe 
oxalic acid by a greater oxidation, and tbat urea and car- 
bonic acid are formed by tbe full oxidation of tb 6' decom- 
posed albuminous tissues ; tberefore, tbat an excess of 
litbic acid, or tbe presence of oxalic acid, in tbe blood, 
implies deficient oxygenation of tbe decomposing tissues ; 
wbicb deficient oxygenation may be owing, eitber to a 
deficient supply of oxygen by respiration, or to tbe pre- 
sence in tbe blood of otber substances witb wbicb tbe 
oxygen will unite in preference, sucb as tbe non-azotised 
aliments. 

On tbis supposition, vegetable food must be improper 
wben tbe litbic diatbesis exists, and exercise must be 
tbe cbief preventive ; and tbis be considers to be sup- 
ported by tbe fact, tbat tbe carnivorous mammalia, con- 
suming mucb oxygen and taking only azotised aliment, 
tbrow off urea only, wbile serpents, consuming little 
oxygen, tbrow off litbic acid only from tbe kidneys. 

But tbis goes on tbe supposition, tbat tbe litbic acid 
and urea come solely, as we can bave no doubt tbat 
tbey do ixirtly, from tbe products of absorption of tbe 
decomposed tissues of tbe body itself, acted on by tbe 
oxygen ; whereas it has been generally thought, that 
these are in part furnished by tbe aliments themselves ; 
and for this opinion, we can give these reasons ; 

1. That excretion in general appears from various 
facts, as to vegetables as well as animals, to be essential 
to the assimilation of aliments, and not merely intended 
for the discharge of the products of absorption. 2. That 
tbe excretion of urine itself, and especially tbe quantity 



CHRONIC DISEASES OF ASSIMILATION. 



649 



of urea contained in it, appear to be much regulated, 
and very quickly altered by the nature of the ingesta, 
being much increased within a very short time after much 
fibrin has been swallowed.* 

Now, if the lithic acid is partly formed by the action 
of the oxygen on albuminous matter taken into the sto- 
mach, its formation will be increased when that matter 
is in large quantity, and may be much diminished by 
the use of vegetable food, with which the oxygen unit- 
ing in preference will leave the albuminous matter un- 
touched, to be applied to the purpose of nutrition. 

Accordingly, experience has often shewn, that the 
lithic diathesis has been much diminished by the use of 
vegetable food, e. g. as recommended by Magendie ; and 
we know that, when connected with gout, it is very gene- 
rally found to be increased by the free use of animal 
food and of fermented liquors containing much gluten 
or " vegetable fibrin."f Even supposing that all the 
lithic acid and urea are formed by the transformation 
of textures ; still, if that transformation, and the absorp- 
tion of materials for formino: these excretions, can be 
rapidly increased by the use of highly azotised ingesta, 
and diminished bv non-azotised food, this last will be 
useful in diseases which depend essentially on more of 
the products of that absorption existing in the blood, 
than the oxygen taken in at the lungs can thoroughly 
oxidize. 

There are, therefore, two objects which theory enables 
us to understand to be essentially important in the 
management of such cases : First, That the azotised 

* See Willis on Functional Disorders of the Kidneys, 
f See Liebig's Animal Chemistry, p. 47. 



650 OUTLINES OF PATHOLOGY AND PRACTICE. 



ingesta be, sooner or later, duly oxygenated, so as to form 
urea rather than lithic acid : Secondly, That the quan- 
tity of azotised food, ultimately the chief pabulum of 
both, be restrained ; and of these objects the former is 
usually less under our power than the latter. 

All that we are as yet justified in concluding, there- 
fore, is, what is certainly in accordance with practical 
observation, that the lithic diathesis is diminished by the 
use of such food only, as is easily and speedily digested 
and assimilated, and by pure air and much exercise. 

It is also certain, that this tendency in the urine is 
much promoted by acidity, especially by the formation 
of much of the lactic or acetous acid at stomach, leading 
to unusual acidity in the urine ; because such acids, com- 
bining with the earthy and saline bases in the urine, set 
free the lithic acid alone or with ammonia, a super-salt, 
which is sparingly soluble and is thrown down. Ac- 
cordingly, acidity at stomach is found to increase, and 
the habitual use of magnesia, potass, and soda, is dis- 
tinctly found to diminish, the tendency to the deposition 
of the lithic acid or the red sand. 

The tendency to the deposition of the white sand and of 
the Phosphates, appears to depend on a different princi- 
ple. It is seen chiefly either in persons of feeble habit 
of body, weakened by fatigue, anxiety, and poor living, 
or in those who have sufi^ered injury or disease of the 
kidneys. In such persons, the urine is apt to be ammo- 
niacal, in consequence, as Dr Prout and others suppose, 
of the urea undergoing a spontaneous decomposition 
within the body, similar to that in which it is prone when 
out of the body. Even when not sufficient to make the 
urine alkaline, this ammonia unites with the phosphate 
of magnesia, always in solution in the urine, and forms 



CHBONIC DISEASES OF ASSIMILATION. 651 



a triple salt, wliicli is insoluble, and wliich is often 
combined or associated with phosphate of lime, when 
deposited. 

To correct the deposition of the white sand thus sepa- 
rated, generally from pale urine, the Tonic Regim.en as 
far as possible, a nourishing diet, tonic medicines, and 
mineral acids, are proper ; the latter sometimes giving 
such acidity to the urine as controls the deposition of the 
phosphates ; either holding them in solution, or combin- 
ing with the ammonia, which is the main agent in caus- 
ing their deposition. 

The use of Opium in this phosphatic diathesis is like- 
wise certainly often beneficial, probably because the 
injurious influences, which lead to the decomposition 
of the urea, and formation of ammonia, are often com- 
municated through the nervous system, and are coun- 
teracted by the anodyne effect of opium. 

What has been called the Oxalic Diathesis is stated to 
be attended with a more natural colour and transparency 
of the urine than either of the others, and the deposits 
of gravel take place at longer intervals ; but on what- 
ever cause the appearance of the oxalic acid in the urine 
immediately depends, — Vvdi ether on an imperfect assi- 
milation of saccharine aliments, or on the introduction 
of oxalic acid itself in acid vegetables, or on a peculiar 
decomposition of urea, leading first to the formation of 
oxalate of ammonia, — it would seem that this diathesis 
is attended with a weakened state of the system, like the 
phosphatic diathesis, and that animal food, farinaceous 
vegetables, a tonic regimen, and the use of bitters and 
the mineral acids, as in the former case, are the best 
remedies. 

Thus, the kind of diet which is easiest of digestion^ 

i 



652 OUTLINES OF PATHOLOGY AND PRACTICE. 



and the regimen which is found to be most strengthen- 
ing to the stomach, are advisable in all kinds of gravel ; 
pure air and exercise, a truly tonic regimen, and medi- 
cines, so far as they seem to have truly a tonic eflPect, 
are useful in all ; diluent and demulcent liquors are useful 
in all ; and the use of acid or alkaline remedies may be 
guided by the nature of the deposits, — with this caution, 
that different kinds of gravel sometimes succeed each 
other rapidly, so that frequent examination of the urine 
is necessary to enable us to judge what kind of chemical 
remedy is demanded. 



( 653 ) 



CHAPTER V. 

OF CHRONIC DISEASES OF THE OEGANS OF URINE AND 
GENERATION. 

We may divide these simply according to the parts in 
which they reside, and which are in general easily dis- 
tinguished. 

Sect. l^~Of Chrmic Diseases of the Kidneys. 

These, as in other cases, are Functional and Organic. 
Of the Functional the only truly important are, the 
Nephralgia Calculosa, i, e, the local pain and other 
symptoms resulting from irritation of calculi, formed in 
the ways above stated, and the Ischuria Renalis, or sup* 
pression of the excretion. 

I. The pain of Nephralgia, often very acute, situated 
in one lumbar region, or extending into the iliac, is not 
always to be certainly distinguished either from that of 
colic or from that of lumbago, — having, however, usually 
more resemblance to the former, because little affected by 
movements confined to the muscles of the loins, and often 
attended by sickness, and preceded by other symptoms 
of disordered stomach. It is often attended by pain 



654 OUTLINES OF PATHOLOGi' AND PRACTICE. 



stretching down the thigh and leg, sometimes by retrac- 
tion of the testicle, often by some unusual appearance 
in the urine (blood, mucus, or gravel), but it may be 
unattended by any of these. It is generally, yet not 
uniformly, augmented by exercise, especially riding in 
a carriage, or on horseback. Frequently, as may easily 
be understood, it is combined with symptoms of inflam- 
mation (usually sub-acute), especially febrile symptoms, 
hard pulse, and tenderness, either anteriorly or poste- 
riorly. Its nature is sometimes clearly indicated by its 
passing downwards, in the direction of the ureter, and 
then subsiding, and leaving behind it a frequent desire 
to pass urine, and pain in doing so, which again may be 
quickly relieved by the passage of a calculus. 

The violence of this pain may be relieved by the same 
means as a fit of colic, — bloodletting, if there be even 
threatening of inflammation, large warm enemata, fo- 
mentations or the warm bath, and especially by opiates, 
often best given in enema, alternated with mild laxatives. 
At the same time, diluent and demulcent liquors are 
to be freely given ; and if there be any guide to the kind 
of calculus to be expected, from the previous state of the 
urine, the remedies for it mentioned in last chapter. 

Sometimes, within a short time after the descent of 
a calculus into the bladder, its expulsion may be pro- 
cured, by giving an opiate to cause the bladder to become 
distended, — the patient then using the warm bath and 
passing urine in it ; or by the opiate, or (probably better) 
the tobacco enema. Aftervrards, if the indications of 
calculus in the bladder continue, the case falls more pro- 
perly under the case of the surgeon, except in so far 
as it may be relieved by the remedies already mentioned 
for the lithic diathesis, (whereby we may often prevent 



CHRONIC DISEASES OF THE KIDNEYS. 655 



the formation of fresh calculi), by demulcent liquors, freely 
given, and by anodynes, especially the opiate enema. 

II. The Ischuria Renalis, independently of organic 
disease of the kidney, is a rare disease, but has been 
unequivocally observed at various periods of life, usually 
in advanced life ; its causes are unknown, and its attack 
generally sudden and unexpected,- — beginning in some 
cases with rigors ; but it is often unattended, in its course, 
by any indications either of fever or inflammation, and 
leaves behind it on dissection no inflammatory appearance. 
Its course is generally short, and it is fatal, almost if 
not quite uniformly, in the way of Coma, preceded by 
drowsiness, nausea, and more or less of delirium and 
spasms ; exactly similar to, and obviously proceeding 
from the same cause as, the symptoms in cases of granu- 
lar disease of the kidney, where urea has been found 
in the blood, which has acted as a narcotic poison on the 
brain. No effusion or morbid appearance in the brain 
has been found in some such cases. 

Many cases are on record, some of them probably 
resting on insufficient evidence, of long-continued sup- 
pression of urine, generally in connexion with hysteria, 
from which there was recovery, hardly referable to any 
remedy, but most probably owing in a great measure to 
the discharge of the animal matter of the urine by an- 
other outlet (as in the case of the granular disease for- 
merly considered). In a few cases, in which suppression 
has certainly existed for some days, the secretion has 
returned under the use of strong diuretic medicines, 
mercury, digitalis, and cantharides, preceded sometimes 
by general or local bloodletting. 

In some cases it has appeared, that obstruction to the 



656 OUTLINES OF PATHOLOGY AND PRACTICE. 



excretion of urine by the ureters or bladder has been 
attended, after a time, by similar symptoms of affection 
of the brain; but certainly, there are many cases of 
such obstruction lasting long, leading to irmch absorp- 
tion of urine, and often to much distension of the ureters, 
in which no such consequences resulted; illustrating ap-. 
parently the principle formerly laid down, that re-ab- 
sorbed excretions (probably altered in the process) are 
less dangerous to the system than retained excretions. 

III. The most important organic disease of the Kid- 
neys is the Granular Degeneration, with light and albu- 
minous urine, formerly considered, because often a con- 
sequence of inflammation, but which often comes on in- 
sidiously, without inflammatory symptoms, becomes asso- 
ciated with various other diseases, and may be fatal in 
various ways, already considered ; when running its 
course uncomplicated, this disease ultimately produces 
almost complete suppression of urine, and is fatal by 
coma, exactly like that of the ischuria renalis, although 
more gradual in its accession. The nature of the lesion 
in such cases is considerably various ; but the general 
result is, that the cortical or secreting portion of the 
kidneys is disorganized by adventitious matter deposited 
in it, very generally nearly symmetrically in the two 
organs. 

The other organic diseases to which the kidneys are 
liable, are much less easily recognized during life, and 
indeed are most generally to be regarded only as parts 
of other diseases, the symptoms of which are often more 
obvious. These are the following : — 

1. Serous cysts are often formed on the external sur- 
face of the kidneys ; sometimes true hydatids form there 



CHRONIC DISEASES OF THE KIDNEYS. 



657 



also ; these cysts, wlien numerous and large, ultimately 
cause absorption of much of the glandular structure ; 
and may therefore produce suppression of urine. More 
generally, this lesion, when extensive, is either com- 
bined with the granular disease, or with intercurrent 
inflammation, and is fatal by means of these complica- 
tions. 

2. Malignant de]30sits, most generally of the larda- 
ceous, or the encephaloid kind, sometimes affect one or 
both of the kidneys, either alone or in connection with 
similar deposits in other parts. These are attended with 
more or less of albumen in the urine, and are there- 
fore hardly to be distinguished during life, from the 
more common granular disease ; but in some cases the 
encephaloid disease, as in the cases called Fungus 
Heematodes on the surface of the body, is attended with 
repeated haemorrhage, and sometimes such morbid mat- 
ter has made its way, after adhesion and ulcerative ab- 
sorption, into the adjacent vena cava, and stopped the 
circulation. 

3. The Ureters are sometimes permanently obstructed 
by morbid deposits {e. g. tubercular matter) in their own 
textures ; sometimes by calculi descending from the 
kidneys, and impacted into them ; but more frequently 
by tumors of some of the neighbouring viscera com- 
pressing them j and the effect of their obstruction and 
distension, in causing gradual, but ultimately enormous 
dilatation of the cavities, and absorption of the kidneys, 
has been already noticed. When both ureters are affected 
in this way, to such a degree as to cause wasting of the 
glandular substance of the kidneys, the symptoms of 
ischuria renalis must naturally be expected. 



' 658 OUTLINES OF PATHOLOGY AND PRACTICE. 



Sect. II. — Of Chronic Diseases of the Bladder. 

Tlie only functional diseases of this organ that de- 
mand notice, are the following : — 

1. An Irritable Bladder^ independently of any or- 
ganic disease, occurs not unfrequently in hypochondri- 
acal and hysterical persons, and is indicated by frequent 
and painful passing of urine, when nothing morbid can 
be detected, either in the bladder, prostate, or urine 
that is voided. It admits of some degree of relief from 
anodynes (particularly in enema); from alkalies, from 
demulcents, from preparations of iron, and mineral 
acids ; but is often more permanently relieved by change 
of scene, and the different articles of the tonic regi- 
men. 

2. In women, and generally in connection with hys- 
teria, a spasmodic Ischuria Yesicalis is not uncommon, 
and often excites unnecessary alarm. When uncon- 
nected with other disease, it is often relieved by emol- 
lient, stimulant, or anodyne enemata, and by the spi- 
ritus setheris nitrosi, with preparations of iron, and by 
the warm bath ; and the most important caution in re- 
gard to it is, that the catheter should hardly ever be 
used to relieve it, in such patients ; for if it is once used, 
the patient is very apt to become dependent on it after- 
wards. The complaint seems to depend on a defect of 
the voluntary effort requisite for passing the urine, and, 
like others of the same kind, is not benefited by that 
voluntary effort being made unnecessary."^ 

The Bladder of Urine, like the heart, undergoes 
changes of its structure much more frequently, in con- 

* See Brodie on Diseases of the Urinary Organs. 



CHRONIC DISEASES OF ORGANS OF GENERATION. 659 



sequence of disease of its lining membrane, or of the 
passage leading out of it, than from morbid deposits in 
its muscular substance. 

The inflammation of its mucous membrane, formerly 
considered (^e. g. that which results from injuries of the 
spinal cord), leads to thickening of its muscular fibres, 
and contraction of its cavity, "vvhich of course implies 
frequent irritation, and evacuation of the bladder ; and 
the same results follow from whatever permanently irri- 
tates its inner surface, or opposes the exit of the urine ; 
therefore, from morbid growths, which sometimes origi- 
nate in its mucous membrane, particularly flocculent 
or fungoid deposits, nearly of the encephaloid kind, not 
uncommon in advanced life, — from calculi lodged in it, 
from enlargement of the prostate, or stricture of the 
urethra, — causes of difficult excretion of urine which re- 
quire to be carefully distinguished by surgical examina- 
tion, but of the diagnostics and treatment of which it is 
not necessary to treat here ; the medical treatment being, 
indeed, almost entirely palliative, and consisting chiefly 
in the habitual use of demulcents and anodynes, with 
occasional local depletion, where inflammatory symp- 
toms supervene. 



Sect. III. — Of Chronic Diseases of the Male Organs of 
Generation, 

The disease of the Prostate Gland, which is common 
in advanced life, consists sometimes of mere enlarge- 
ment, but often of a gradual change of its substance, 
similar to that which often takes place in the cellular sub- 
stance connecting the coats of the stomach and bowels, 



660 OUTLINES OF PATHOLOGY AND PRACTICE. 



until it has assumed the appearance of a scirrhous 
tumor. Strictures of the urethra very generally result 
simply from lymph effused by inflammation immediately 
behind the mucous membrane ; but in some cases this 
lymph is gradually altered, and becomes ultimately car- 
tilaginous. 

The medical treatment required in such cases is de- 
manded either by attacks of inflammation or of spasm, 
and consists, therefore, chiefly in local bleedings, the 
warm bath, and anodynes. Deobstruents are clearly 
indicated, but in general found quite unavailing. 

It is difficult to be certain as to the existence of func- 
tional disease of the other Male Organs of Generation, as 
distinguished either from the excitement of vicious prac- 
tices, or the impotence consequent on vicious indulgences, 
or the very common hypochondriacal feeling, which sup- 
poses impotence to exist, when it has only been deserved. 
This last feeling is often much aggravated by the arts of 
empirics, and becomes a source of much misery, or a cause 
of partial insanity ; but for all these evils, moral reme- 
dies only can really avail ; and if all unnatural or exces- 
give excitement is really avoided (which is more generally 
effected indirectly, by otherwise occupying the mind, than 
by direct exhortation), — if the aggravated representations 
of interested empirics are prevented from impressing 
themselves too strongly on the mind, — and exercise, cold 
bathing, and other tonic remedies, are carefully employed, 
the natural functions of these parts may often be suc- 
cessfully, although gradually, restored. 

The " Gonorrhoea Dormentium" occurring only occa- 
sionally in young and healthy persons, is to be regarded 
as an indication of health, not of disease ; but it is cer- 
tain, that a morbid state of sensations, prompting to se- 



CHRONIC DISEASES OF ORGANS OF GENERATION. 661 



minal discharges, and in some instances such discharges, 
without pleasurable sensations, may occur from an ir- 
ritable or rather morbidly sensible state of the prostatic 
portion of the urethra (just as they appear to proceed 
sometimes from organic disease of the prostate), — even 
in a feeble or exhausted constitution ; and it appears to 
be well ascertained, that the tendency to involuntary 
emissions of this character, may be corrected by reme- 
dies, — sometimes by leeching on the perineum, — more 
frequently by passing the bougie, or by the cautious 
application of caustic to that portion of the urethra, — 
sometimes by the cautious use of anodynes, while the 
general health may be improved by a tonic regimen. 

The morbid changes of structure, to which the Testes 
are liable, besides simple enlargement, and sometimes a 
peculiar kind of fungous growth, with destruction of the 
glandular structure, described by Mr Lawrence, — which 
are consequences of inflammation, — are the results of 
deposition, either of tubercular matter, or of the en- 
cephaloid matter, or of the true scirrhus. All these 
complaints, being usually regarded as surgical, require 
no detailed notice here. They can hardly be distin- 
guished from the effects of chronic inflammation, or 
from each other, in their earliest stage ; but the dif- 
ferences become obvious, as the organ enlarges, — as the 
spermatic cord, and neighbouring glands are, or are not 
affected, and as the general health, or distant organs, 
are or are not involved. In the two latter cases the 
prognosis is necessarily unfavourable, and even the 
chance of successful operation, unless in the earliest 
stage, is very small ; but in some cases, which would 
seem to be of the two former kinds, the usual remedies 

PART III. V u 



662 OUTLINES OF PATHOLOGY AND PRACTICE. 



for chronic inflammation, a very careful regimen, and 
the cautious use of Mercury and of Iodine, are suc- 
cessful. 

Sect. IV. — Of Clfivomc Diseases of the Uterus and 
Ovaria, 

These, as usual, we divide into Functional and Or- 
ganic. 

I. It has been already stated, that there are many cases 
of the more chronic forms of inflammation of the Ute- 
rus, tending either to simple enlargement, or to effiision 
of lymph into the cavity, or even to ulceration, which 
are unattended with fever, of long duration, and often 
disting-uished with difficulty from, or graduating into, 
the more dangerous chronic diseases depending on de- 
position of heterologous matters. A similar connection 
often exists between the chronic inflammations of the 
uterus, and the following, which are properly to be re- 
garded as its functional diseases, beca.use often existing 
long, and causing much uneasiness, and nevertheless ad- 
mitting of perfect recovery, without perceptible altera- 
tion of the texture of the organ remaining. 

1. The state of Amenorrhoea, i. e, the Emansio men- 
slum, where the menstrual discharge does not appear 
after the usual period of puberty has arrived, and the 
other marks of puberty have shewn themselves, — or 
the Retention of the menses, i. e. their non-appearance 
at the usual periods, after they have been established, 
— must be carefully distinguished from the sudden Sus- 
pension of the menses, i, e. the interruption of the flow, 
when taking place at the usual period. 



CHRONIC DISEASES OF THE UTEEUS, &C. 663 



111 the former case, the changes at the Ovaries, which 
we have reason to believe to be the immediate cause of 
the act of menstruation (probably the discharge of a fully 
developed ovum at each period), do not take place ; in 
the latter, these changes go on for a certain time, and 
the increased flow to, and secretion from, the inner sur- 
face of the uterus, consequent on them, is established, 
and then the whole series of changes is interrupted, 
usually by some sudden impression on the nervous sys- 
tem, checking the determination of blood to that part, 
or inducing other determinations. 

The retention of the menses is often the efl'ect of 
diseases of other parts of the body, and only a sign of 
general feebleness of habit, produced by other diseases, 
as, g, when it occurs in Phthisis ; but in other cases 
it seems to result from causes acting peculiarly on the 
ovaria, and the affection of other parts appears to be 
secondary, as when dyspepsia and hsematemesis (rare in 
other cases of functional dyspepsia) supervene on this 
state. And the action and reaction of this and other 
functions of the body on one another are such, that it is 
often very difficult to judge whether amenorrhoea should 
be regarded as the cause, or only as the sign, of other 
derangements of the health. But there can be no diffi- 
culty about regarding it as the cause, when, as often 
happens, it occurs in a constitution apparently strong or 
even plethoric. Even when occurring in constitutions 
otherwise feeble, if not the immediate cause, it is very 
generally a great aggravation ; and if the health is not 
suffering from organic disease, this part of the complaint 
is a fit object of practice. 

The indications of enfeebled constitution, indepen- 
dently of organic disease, which we usually observe to be 



664 OUTLINES OF PATHOLOGY AND PRACTICE. 



produced or aggravated by Amenorrhoea, and to be re- 
lieved by a restoration of tbe menstrual flux, are those 
known by the name of Chlorosis ; of which state the most 
essential constituent probably is, the deficiency of the 
red globules of the blood, which have been known to be 
reduced as low as 29 in the 1000, instead of 125 or 130, 
their usual proportion (Andral). With this are con- 
nected paleness, or a yellowish, or even greenish colour 
of the skin, deficient nutrition of all parts, slight anasarca, 
coldness of extremities, muscular debility, generally a 
costive state of the bowels ; a morbidly irritable but 
feeble state of the heart's action, resembling the reac- 
tion after loss of blood, and shewn by palpitation and 
breathlessness, often alternating with tendency to syn- 
cope, and sometimes attended with temporary unnatural 
sounds ; and an unnatural mobility of the nervous sys- 
tem, shewn by various uneasy sensations and morbid 
cravings at stomach, neuralgic pains, and mental agita- 
tion easily produced by sudden impressions on the senses, 
particularly the hearing. 

With this state of the system, the following more 
local affections are very frequently associated : — 

(1.) Severe dyspeptic symptoms, much vomiting, and 
not unfrequently Hsematemesis, which usually gives great 
relief to the feelings of the patient, and, although going 
to a great extent^ is seldom dangerous, when clearly 
traced to this cause. 

(2.) Very various uneasy sensations, flatulent distension 
of the intestines, and slighter spasms of the voluntary 
muscles (usually rather the effects of peculiar perversion 
of the will, than strictly involuntary), which are gene- 
rally referred to the head of Hysteria ; in some cases, 
more violent and really involuntary spasms, with insen- 



CHEONIC DISEASES OF THE UTERUS, &C. 665 



sibility, to whicli the name Uterine Epilepsy has been ap- 
plied. 

(3.) Various modifications of the mental faculties, 
likewise often called Hysterical ; sometimes merely the 
capricious or irritable state of the mind, sometimes the 
state of Reverie or extase, and sometimes transient 
fits of delirium, or even more permanent forms of In- 
sanity ; aQiong which we may perliaps inchide a singu- 
lar propensity to practise deception, and thereby excite 
attention and sympathy, against which practitioners must 
always be prepared. 

All these have been often seen to abate when the 
menstruation has been restored, and admit, therefore, of 
a better prognosis, when connected with Amenorrhoea, 
and when there is no evidence of organic disease of the 
parts immediately affected, than in other cases. 

Women in the state of Amenorrhoea are likewise lia- 
ble to sudden inflammatory attacks, in the chest, more 
frequently in the uterus itself, or somewhere in the ab- 
domen, and not unfrequently in the head (which may be 
acute or subacute, of healthy or scrofulous character, 
according to their previous habit of body) ; — perhaps 
more than those equally weakened by other causes. 

All the more acute forms of these secondary affec- 
tions are still more frequently seen when there has been 
sudden interruption, than when there has been reten- 
tion, of the discharge. 

The remedies proper to be employed in cases of 
Amenorrhoea must depend partly on the nature of these 
secondary affections, and partly on the state of the ge- 
neral health and strength, which attend the suspension 
or obstruction of the discharge. 



666 OUTLINES OF PATHOLOGY AND PEACTICE. 



When there are clear indications of inflammation, 
especially in a case of recent suspension, the antiphlo- 
gistic remedies are not only admissible on account of it, 
even in a feeble habit, but may often be more effectual 
than any other means in restoring the discharge itself. 
In like manner, Hemorrhage from the lungs requires loss 
of blood in this case equally as in others ; and Hsemorr- 
haoie from the stomach, if attended with fulness and 
hardness of pulse, is much benefited by it likewise, al- 
though it has been found that this last affection is often 
successfully relieved by free purging only. And al- 
though there be no distinctly inflammatory or hsemorr- 
hagic symptoms, if the case be recent, and the system 
tolerably plethoric, cupping, or leeches applied, about 
the expected period, to the groins or pudenda, or, as 
has been stated, to the mamniEe, and purgatives, particu- 
larly aloetic, with the warm hip-bath, and stimulating 
enemata, sometimes followed by the opiate enema, have 
been found the most effectual means. 

But in cases of some standing, where the symptoms 
of Chlorosis exist, our reliance must be on medicines 
called Emmenagogues, which seem to act in some de- 
gree specifically on the uterus and ovaria, and at the 
same time on means of improving the general health. 

The preparations of Steel (whether they have a spe- 
cific power on the uterus, or, as some suppose, on the 
constitution of the blood, particularly its globules), 
may generally be prevented from injuriously affecting 
the head, by combination with Aloes or Rhubarb ; and 
if alonof with them the stimulatino; Gum-resins, as Mvrrh 
and Galbanum, are taken regularly for some weeks to- 
gether, they are the surest remedies of this kind that we 
possess ; but other means seem, to a certain degree, like- 



CHEOXIC DISEASES OF THE UTERUS, &C. 667 



wise eflPectual, particularly Hellebore, the oil of Savine, 
Turpentine, Cantharides, small doses of the Ergot, Elec- 
tricity ; — the latter of which appears, from recent obser- 
vations, to be one of the most powerful direct remedies, 
but only serviceable when the general health is good, or 
has been so far restored by other means.* 

The articles of the Tonic Regimen, most important 
in such cases, are exercise, on foot or on horseback, as 
far as can be borne without fatigue, and in general gra- 
dually extended ; pure air, changes of scene, and other 
means of mental excitement, inciting to exercise ; the 
Saline and Chalybeate mineral waters; the tepid 
shower-bath, and, when the strength will permit, the 
cold-bath — more generally tepid spunging, and dili- 
gent frictions ; — a light nourishing diet, with as much 
albuminous food, and fermented liquor, as can be taken 
without offending the stomach. By the use of these 
means, the morbid sensibility, which is the immediate 
cause of many of the symptoms, and which is aggra- 
vated by any considerable depletion, may often be gra- 
dually corrected, and if the disease is uncomplicated, 
health is frequently restored. 

The state of Dysmenorrhoea, or painful, and often 
deficient menstruation, is generally gradually relieved by 
perseverance in the use of some of the means now stated, 
both during the interval, and at the menstrual periods, 
particularly a course of Steel, and the hip-bath and 
opiates, or other anodynes, and sometimes cupping on 
the loins. 

2. The state of Menorrhagia, i. e. of too frequent, or 
too long-continued, or profuse menstruation, sometimes 
attended with such a change on the secretion of the 
uterus that the discharge contains coagula of blood, is 
* See Guy's Hospital Reports. 



668 



OUTLINES OF PATHOLOGY AND PRACTICE. 



nevertheless often a merely functional disease ; and when 
ascertained, by examination, to be unconnected with orga- 
nic change of structure of the uterus, is to be regarded in 
many cases as on a footing with other hsemorrhages, most 
easily produced in a plethoric constitution ; but, when 
little exercise is taken, when the nervous system is habi- 
tually excited, by various causes which strongly impress 
the nervous system, or which suddenly disturb the 
circulation, and the general strength thereby impaired : — 
when it lastslong, frequently recurs, and is associated 
with a discharge of Leucorrhoea in the intervals, — it 
becomes a cause of extreme weakness and Anoemia, and 
in fact, of symptoms exactly similar to those of Chloro- 
sis ; the tendency to these discharges, once established, 
cannot be corrected without much care ; and partly, no 
doubt, by a strictly nervous sympathy, partly by the 
deteriorated condition of the blood, the general health 
suffers nearly as in aggravated cases of Amenorrhoea : 
dyspeptic and hysterical symptoms are particularly fre- 
quent, and various affections of the nervous system shew 
themselves ; although seldom so peculiar, or so obstinate, 
as some of those which attend Amenorrhoea. 

The morbid conditions of the parts, on which the 
monorrhagia depends, are, a frequently augmented de- 
termination of blood to the uterus, enlargement and 
flaccidity of its substance, and a state of turgescence, 
though generally without much sensibility, of its mu- 
cous membrane. 

During the continuance of the discharge, it must be 
treated on the footing of a hsemorrhage, sometimes by 
loss of blood, always by mild laxatives, particularly the 
saline with acids, by rest in the horizontal posture, the 
antiphlogistic regimen, the application of cold to the 



CHRONIC DISEASES OF THE UTERUS, &C. 669 



lower part of the body, and the use of astringents, the 
sulphuric acid, small doses of Alum, or of Acetate of 
Lead, or the Gallic acid : in some cases the peculiar 
action of the Ergot, in exciting contraction of the uterus, 
has been availed of with success, or the mechanical com- 
pression by a plug in the vagina may be requisite. 

In the intervals of the discharge, much may be done 
to diminish the tendency to its recurrence, by such parts 
of the tonic regimen as the patient can bear ; by cold 
bathing, gentle exercise,, and fresh air, light diet, regu- 
lar hours, avoiding all strong excitements mental or 
bodily, and by the use of medicines of the class of 
Tonics and Astringents, particularly the Sulphate of 
^ Quinine, Sulphate of Zinc, Alum, and Kino, or by the 
daily use of injections, cautiously tried, consisting of 
solutions, particularly of the Zinc and the Alum. 

The more permanent discharge of Leucorrhoea, often 
likewise found to be unconnected with organic change of 
structure, and probably proceeding more from the mu- 
cous membrane of the vagina and os uteri than of the 
uterus itself, is often associated with more or less of the 
Menorrhagia, but sometimes with a deficient state of 
the menstrual discharge : although sometimes commen- 
cing in full and strong habits, it is always attended, after 
a time, with much debility, a deficiency of the colouring 
matter of the blood, and many dyspeptic and hysterical 
symptoms. It is, however, very frequently relieved by 
the tonic and astringent means above stated — or in ag- 
gravated cases, by absolute rest in the horizontal pos- 
ture for a time, with pretty constant application of ni- 
trate of silver or of iodine (considerably diluted) to the 
OS uteri, and afterwards by the tepid or cold bath, pure 
air, and gentle exercise. 



670 



OUTLINES OF PATHOLOGY AND PRACTICE. 



3. Often in connection, either with the Amenorrhoea 
or the Menorrhagia, and sometimes independently of 
either, we meet, as was formerly observed, with the 
Hysteralgia, or irritable uterus, indicated simply by 
pain in the situation of the uterus, liable to frequent 
aggravations, particularly from exertion or excitement, 
and attended with extreme tenderness of the os uteri, 
but without any inflammatory symptoms or change of 
texture — demanding rest in the horizontal posture, and 
anodynes locally or generally — sometimes relieved by a 
little local bleeding, generally aggravated by purging, 
and most permanently relieved by the use of steel or 
quinine, in small but gradually increasing doses, and by 
as much of the tonic diet and regimen, gradually em- 
ployed, as the frequent recurrences of pain will permit. 

II. The organic diseases of the Uterus and Ovaria 
constitute a numerous and important class, demanding 
much attention, and capable of being accurately discri- 
minated ; some of them admitting of effectual relief from 
surgical treatment, most of them, however, only of pal- 
liation from the care of the physician. Of these we 
give here only a general outline. 

Organic disease of the Uterus may always be sus- 
pected when morbid discharges from the vagina are 
obstinate, particularly if they occur towards the end of 
the period of menstruation, or after menstruation is 
over, — if they consist of matter different from the men- 
strual flux itself, or the simply mucous discharge of 
Leucorrhoea, — and if they are attended by much pain 
extending down the limbs, or by progressive debility and 
emaciation. But they can, of course, only be accurately 
known by examination. Here, as in other parts, there 



CHRONIC DISEASES OF THE UTERUS, &C. 671 



is an essential distinction between the local and simply or- 
ganic, and tlie constitutional or even malignant growths ; 
which distinction is in some cases obvious, but in others, 
at least for a time, is obscure or ambiguous. 

1. Within the cavity of the uterus, various morbid 
formations may take place on its mucous membrane, by 
some of which it may be distended, and even its cervix 
expanded, as by the development of the foetus. The 
simplest in its mode of formation, appears to be the 
tumour occasionally seen there, which consists of layers 
of partially decolorized crassamentum of blood, like the 
contents of an aneurism, formed by a morbid alteration 
of the menstrual excretion, and apparently, from the 
increase of uneasy feelings at stated intervals, receiving 
an increase of bulk at the menstrual periods. The next 
in point of simplicity are the Polypi, often growing 
within the uterus, and projecting into the vagina; which 
seem in some cases to originate likewise in coagula of 
effused blood, and which are usually attended with fre- 
quent and profuse hsemorrhage. Many such polypi have 
been removed without reproduction or extension of the 
disease, and a complete cure obtained ; while others ap- 
pear only to be a part of constitutional disease, and 
their removal is only a temporary benefit. Again, in 
some cases a mass of Hydatids, and in others a single 
sac containing a serous or bloody fluid, has been found 
to occupy the cavity of the uterus, and the contents of 
such sac have been repeatedly discharged by the vagina. 
And in unhealthy constitutions masses of the encepha- 
loid matter have also been formed here, perhaps in some 
instances by transformation of effused blood. 

2. In some instances the muscular substance of the 
uterus has been found pre ter naturally hard, and in others 



672 OUTLINES OF PATHOLOGY AND PRACTICE. 



preternaturally soft, without decided previous inflamma- 
tion; and in many cases Ulceration, beginning on tlie 
mucous membrane at the os tinea), gradually pervades 
tlie organ, causing purulent and fetid discharge, with 
very little of inflammatory symptoms, and with no 
deposition of adventitious textures preceding it. This 
case likewise admits, in some cases, of permanent relief^ 
probably most effectually by destruction of the part af- 
fected by some chemical cautery. 

In some cases, likewise, it appears that changes of 
position of the uterus, particularly a degree of retro- 
version, causing pressure on the rectum, lead to symp- 
toms nearly resembling . those of enlargement and or- 
ganic disease, although its texture be sound, and such 
cases may admit of relief by instruments. 

3. Different adventitious textures are often deposited 
in the substance, or even originally just beneath the 
peritoneal coat of the uterus. Of these the most com- 
mon are the Fibro-cartilaginous tumors, which although 
often closely resembling the true scirrhus in structure, 
yet, when growing quite distinct from the natural tex- 
tures, may be found in considerable numbers, attain a 
great size, last long perfectly inert, and cause no symp- 
toms, excepting what may result from their pressure 
on the adjoining parts. The Medullary Sarcoma, ad- 
mitting here as elsewhere, of considerable variety, some- 
times even in the same subject, from the soft encepha- 
loid to the firm lardaceous deposit, and the true Scirrhus, 
are more intimately intermixed with the muscular tex- 
ture, and sometimes with each other. These are almost 
uniformly first deposited at the os tincse and cervix 
uteri, causing enlargement, irregularity, and generally 
hardness of these parts ; and go on to ulceration, begin- 



CHEONIC DISEASES OF THE UTERUS, &C. 673 

ning at the os tincse, causing much^fetid discharge, and 
infaUibly spreading through the substance of the organ ; 
frequently spreading likewise through the coats of the 
rectum or bladder, so as to establish unnatural commu- 
nications ; and sometimes through the peritoneal cover- 
ing of the uterus, so as to allow the escape of the mor- 
bid secretion into the cavity of the abdomen, and excite 
rapidly fatal peritoneal inflammation. 

These last diseases sometimes appear to commence 
with inflammatory symptoms, or at least with increased 
determination of blood to the uterus, denoted by uterine 
haemorrhage after the period of the cessation of the 
menses, before any puriform discharge begins ; but such 
symptoms are not always observed, and even when they 
are, it may often be suspected that an unperceived per- 
version of the nourishment of the part had preceded 
their appearance : they are attended generally with 
severe pain, referred to the back and lower limbs, as 
well as to the pelvis, but liable to great and long con- 
tinued remissions ; and with rapid sinking of strength, 
frequently febrile symptoms, sometimes distinct hectic, 
and ultimately extreme emaciation. 

In regard to all organic diseases of the uterus, it is to 
be remembered, firsts that they are very generally at- 
tended with various sympathetic sensations, and with 
sympathetic derangement of the functions of other parts, 
particularly the stomach ; and secondly^ that many of the 
symptoms that are very urgent in such cases may de- 
pend on the pressure of the diseased and enlarged ute- 
rus on the neighbouring parts, and on the chronic in- 
flammation excited, and unnatural adhesions frequently, 
though not uniformly, formed among these ; especially, 
as has been already stated, when the morbid growth is of 



674 OUTLINES OF PATHOLOGY AND PRACTICE. 



a malignant kind, ^Thus dysuria from such affection of 
the bladder, dysenteric symptoms from such affection 
of the rectum, in some instances disease of the kidneys 
from distention of the ureter, and in many colic pains, 
constipation, vomiting, &c. from adhesions of the folds 
of ileum in the pelvis, combine themselves with those 
of the diseased uterus. In some instances, symptoms 
also arise from the enlargement and degeneration of 
lymphatic glands within the pelvis, consequent on such 
diseases of the uterus, e, g, anasarca of one or both of the 
lower extremities from pressure on the iliac veins. 

In some instances, the Fallopian tubes are distended 
by serous cysts ; or these tubes, and the broad ligaments 
of the uterus, are besQt with different kinds of morbid 
growths, which may have effects on the adjacent viscera, 
similar to those just now described. 

When the existence of such disease is ascertained, 
palliative remedies can only be employed ; occasional 
local bleedings when inflammatory symptoms super- 
vene, the warm hip-bath, opiates and other anodynes, 
chiefly in ^nema, mild but effectual laxatives, a light 
nourishing diet, and the horizontal posture, with the 
use of mepuis to prevent excoriation from pressure. 

The most common disease of the Ovaria is the forma- 
tion of encysted tumours (generally several in one ovary), 
which appear sometimes to commence as serous cysts, 
unconnected with the sound texture of the organ, but 
frequently are formed by the distention of the Graafian 
vesicles, and which often attain an enormous size ; some- 
times, in their advanced stage, hardly to be distinguished 
from the Ascites abdominalis. The contents of these 
are very various even in the same ovary ; serous, gelati- 
nous, atheromatous, or purulent; and in other instances, 



CHRONIC DISEASES OF THE UTERUS, &C. 



675 



blood, more or less altered from tlie sound state, eiice- 
phaloid matter, or melanosis. In other cases sarcoma- 
tous, fatty, or fibro-cartilaginous tumours form in and 
project from the ovaries ; and in some, these different 
morbid growths are found combined. Many of these 
may subsist long, and cause no symptoms but what de- 
pend on their situation and size, and pressure on adjoin- 
ing parts; but the growth of several of them is pre- 
ceded or attended by occasional pain, tenderness, and 
other inflammatory symptoms, admitting of relief from 
local bleedings : when the encephaloid, perhaps also 
when the melanotic matter is deposited, the general 
health is much impaired, and in the former case espe- 
cially, there are often repeated attacks of inflammatory 
symptoms, followed by increase of the tumours. 

These diseases, likewise, are generally an object only 
of palliative practice. They are certainly not to be com- 
bated by mercurial medicines, which fail of efl^ect on them 
and injure the general health ; but have sometimes ap- 
peared to abate considerably under the long continued 
use of Muriate of Lime, or more particularly of pre- 
parations of Iodine. The paracentesis is the only efl'ec- 
tual palliative for the uneasiness occasioned by the bulk 
of the tumour, and has often been many times repeated 
with temporary advantage, of course only in cases where 
the tumour was not a part of constitutional disease. 
The question of the excision of diseased ovaries belongs 
to surgery. 



( 676 ) 



CHAPTER VI. 

OF CHRONIC DISEASES OF THE NERVOUS SYSTEM AND 
ORGANS^ OF SENSE. 

Sect. I* — Preliminary Observations. 

These diseases cannot be better arranged than was 
done by CuUen, into tbe Comatose diseases, the Spasms, 
the affections of the External Senses, and the affections 
of the Internal Senses, or of the Mind ; although we ex- 
clude from these heads of nervous diseases several which, 
on theoretical grounds, were placed there by Cullen. 

But it is necessary here to remember what was for- 
merly stated as to the difference between the strictly 
pathological and the nosological meaning of the term 
Disease. Many of these diseases of the Nervous Sys- 
tem are perfectly well distinguished by their symptoms, 
and therefore have properly specific names assigned 
them ; but are known to proceed, in different cases, from 
perfectly different morbid actions or changes ; and again, 
the same change may produce, even in the same person, 
a series or combination of very different symptoms, 
such as ought to be referred to different places in a 
merely nosological arrangement. 

That there should be much variety as to the affections 
of sense and of voluntary power, and also as to the af- 
fections of the strictly mental powers, in diseases affect- 
ing the nervous system, is not surprising, when we re- 



CHRONIC DISEASES OF THE NERVOUS SYSTEM. 677 



member certain principles now ascertained in Physiology 
— that the two former powers are directly and imme- 
diately connected only with a small portion of the con- 
tents of the cranium, and that a portion which is not 
often directly injured, — that the conditions necessary to 
the exercise of all the mental faculties may probably be 
furnished by various portions of the nervous matter of 
the hemispheres, — and that all the functions of nervous 
matter may be retained, notwithstanding very consider- 
able changes in the form,, and even in the texture of that 
matter, provided that these changes are gradually ef- 
fected. But making allowance for all these facts, we 
must still admit, that a greater variety than could have 
been expected is observed in the kind, and in th^ dura- 
tion, of the alterations produced in the functions of the 
nervous system in disease, even when the parts injured, 
or the mode of injury, appear to be the same. 

The uncertainty as to the morbid conditions on which 
the symptoms of the strictly nervous diseases may de- 
pend^ makes it right to enumerate all those morbid con- 
ditions, before treating of the nervous diseases in detail. 

We have formerly stated in what manner the func- 
tions of the Nervous System are frequently affected by 
mechanical injury, by heat, cold, electricity, &c. by 
poisons, and by the influence of imperfectly arterialized 
blood in asphyxia; again, how they are often altered, 
either by sudden diminution, or sudden increase of the 
flow of blood to the brain ; by inflammation and its 
consequences ; by the different forms of idiopathic and 
eruptive fevers, and by the kind of inflammatory action 
which frequently accompanies these ; how they are af- 
fected sympathetically, in cases of disordered secretions, 
especially of the primes viae ; and more uniformly in 

PART III. XX 



678 OUTLINES OF PATHOLOGY AST) PRACTICE. 



cases of suppression of excretions, especially of that at 
the kidneys. And we have found that in all these cases 
the affection of the Nervous System may include various 
affections of the external senses, of the muscular parts, 
and of the acts or affections of mind, and that in all it 
may proceed to absolute Coma, and to death from that 
cause. 

In like manner, diseased states of all, or almost all, 
those functions of the Nervous System may be merely 
functional, unattended either by the application of any 
known cause of injury, or by any perceptible lesion, — 
or they may result from diseased structure simply orga- 
nic and local, or from constitutional and even malignant 
disease ; and the progress and ultimate result will very 
much depend on the nature of their cause. But as the 
symptoms, or series of symptoms, marking these diseased 
states of the Nervous System, are in general well marked 
and striking, and as the nature of the change producing 
them is not open to inspection during life, it is neces- 
sary to retain the nosological classification of these dis- 
eases, at the same time that we keep in view the different 
changes which may be concerned in producing each ; or 
several in the same patient, and in rapid succession. 

I. They may be functional only, or result from in- 
jury applied in a degree so very much less than that, 
which is often unattended with any such effect, that 
the action of some additional and unperceived cause is 
clearly manifested. Even in such cases they necessarily 
imply corresponding changes in the Nervous System, 
which is the physical agent coiic^ned in all the func- 
tions now in question j but as all changes, healthy and 
morbid, which take place in the nervous matter, cor - 



CHRONIC DISEASES OF THE NERVOUS SYSTEM. 679 



responding to mental acts, are known to us only by their 
effects, it is impossible for us to clo more, in regard to 
the merely functional disorders of tbe Nervous System, 
than state the symptoms by which they are made known, 
the circumstances in which they are observed, and the 
effects which result from them. 

Two general observations, however, may be made on 
these strictly nervous affections, and their connection 
with the state of the circulation. 1. That as the healthy 
action of any part of the Nervous System, when strongly 
excited, appears to be attended with some increase of 
the flow of blood to that part, and as the total inac- 
tivity of any part usually leads to a diminished sup- 
ply and consequent wasting, — so it is reasonable to sup- 
pose, that a morbid increase of the activity of the changes 
in any portion of nervous matter, although not originat- 
ing in, may readily become attended hy^ an increased de- 
termination of blood thither ; and although we cannot 
affirm that this is a general law, yet many facts in the 
history of diseases indicate that it is a frequent and im- 
portant occurrence. 2. That the state of the Nervous 
System most favourable to the original excitement of 
such nervous disorders, is generally that which attends 
great weakness, and in which both the fulness of the 
vessels, and the strength of the circulation, may be sup- 
posed to be below the average.* 

* In cases of great weakness, from haemorrhage, previous disease? 
or fasting, says Andral, " I'impressionabilite des centres nerveux 
devient souvent d'autant plus grande, que la quantite du sang dimi- 
nue, et que le systeme musculaire s'afFaiblit. Dans cet etat 1' hy- 
peremie la plus legerement douloureuse pent determiner dans le 
systeme nerveux Ics desordres functionaires le plus graves."^ — -Precis^ 
t. i. p, 18. 



680 OUTLINES OF PATHOLOGY xVND PRACTICE, 



II. The diseased states of the functions of the Ner- 
vous System may be, and in fact the most sudden and 
violent affections of this kind often are, the effect of 
haemorrhage, the consequences of which, occurring in 
the substance of the brain, have been carefully studied. 

This heemorrhage takes place generally in persons 
advanced in life, and is preceded most generally, though 
not uniformly, by the circumstances formerly noticed, 
which favour, by the causes which excite, and by the 
symptoms which indicate, an increased determination to 
the head, and consequently obvious, although slight, de- 
rangement of the functions of the brain. 

It takes place most generally in the parts adjacent 
to, or on a level with, the lateral ventricles, especially 
the corpora striata or adjoining parts. It is often obvi- 
ously confined to a spot, and certainly often depends on 
rupture of a single vessel, facilitated by a previously dis- I 
eased state, — an inelastic and brittle, or even ulcerated, 
condition of the arteries there situated. But in other 
cases, no disease of vessels is detected, and, in some, the 
effusion is in many minute points, and could not have 
been produced by rupture, unless of the smallest vessels. ^ 
Such a case is strictly of the kind described as Ha3mor- 
rhage by Exhalation, probably more frequent in other 
parts of the body. 

When the progress of a case of this kind has been 
rapid, softening of the brain is very generally found 
around the clot of blood that has been effused (unless it 
is very small) ; — in the most rapid cases such softening, 
without discoloration, as is obviously the result of the 
mechanical injury done to the nervous matter ; but in 
other cases, such softening, with discoloration, as was 



CHEONIC DISEASES OF THE NERVOUS SYSTEM. 681 



formerly described as indicating inflammation of the 
brain, usually attended with serous effusion into the 
ventricles. In cases of this last kind, it has been often 
disputed, whether the inflammation and softening had 
preceded and led to, or had succeeded and been produced 
by, the effusion of blood. Ju-dging from the different 
progress of cases, we may be assured that the inflamma- 
tion may be connected with the hsemorrhage in both 
ways, perhaps most generally in the latter way. 

When no such extent of disorganization attends the 
effusion of blood, and when its immediate effects on the 
functions of the brain abate, the changes consequent on 
it are, that a thin layer of coagulable lymph is thrown out 
around it, and becomes gradually organized, and that the 
colouring matter of the blood, and afterwards the rest of 
the coagulum, are gradually absorbed from the interior 
of the cyst thus formed ; which is then left, containing 
only a serous fluid, and afterwards shrinks farther, but 
never completely disappears. The substance of the 
brain around it sometimes remains permanently dis- 
coloured and hardened. It is certain that the absorp- 
tion of the coagulum may be effected in this way within 
three months after its effusion. 

Perhaps the most uniform of all the diseased states of 
the functions of the Nervous System, consequent on or- 
ganic lesion within the brain, is the occurrence of Hemi- 
plegia, more or less complete, in the opposite side of the 
body from the side of the brain where this effusion has 
occurred ; and the gradual, but very variable and sel- 
dom complete, recovery from that and other morbid con- 
ditions thus produced, during the progress of the absorp- 
tion now described. 



682 OUTLINES OF PATHOLOGY AND PEACTICE. 



III. Almost every other known variety of organic dis- 
ease has been repeatedly observed to affect the contents 
of the Cranium, — al], or almost all, sometimes appear- 
ing to originate in an inflammatory attack (e. g. from an 
injury), and at other times appearing merely as results of 
perversion of nutrition, without any such precursor. The 
bones of the cranium are sometimes found of unusual 
form or thickness, and appear to have compressed the 
contents. Exostoses from the inner table, and sometimes 
tumours, even passing inwards through the bone, from 
the pericranium, have been found to compress and irri- 
tate parts of the brain. The dura mater has been found 
partially thickened, ossified, or beset with tubercles, or 
other kinds of tumour. Attached to the pia mater on 
the surface, or to the membrane continuous with it in 
the ventricles, or detached from any of the membranes 
in the substance of the brain, we often find scrofulous 
tubercles, especially in younger subjects, of very various 
number, and in various '^stages of progress ; sometimes 
the medullary sarcoma, or other morbid growths of 
the kinds which affect the general habit ; sometimes 
more isolated tumours, and these either encysted and 
containing serum (as is frequently seen in the choroid 
plexus, and sometimes on the surface of the brain), 
or blood ; or of the class described as sarcomatous, or 
fibro-cartilaginous, or even bony. We have also ex- 
amples of injurious effects on the brain, evidently result- 
ing merely from a diseased state of the vessels, enlarge- 
ment or aneurisms of the arteries, or partial obstructions 
either of these or of the sinuses, from diseases of their 
lining membrane, without rupture. 

Again, besides the hardening and softening of the 
substance of the brain, which were described as efi'ects 



CHRONIC DISEASES OF THE NERVOUS SYSXEM. 683 



of inflammation, either more acute or more chronic, we 
meet with some examples of both those changes of con- 
sistence in portions of the brain, without change of 
colour, or any clear evidence of inflammation ; and in 
other cases, with the hypertrophy, formerly described, 
of the whole cerebral substance, or more partial atro- 
phy of the nervous matter. 

Along with almost all these organic lesions within 
the cranium, serous effusion into the ventricles is often 
found ; and in many cases of persons advanced in life, 
without any enlargement of the skull, — and in children 
where the sutures have yielded and the bead become 
enlarged (sometimes to an enormous extent), — we see 
much effusion into the ventricles, without the indications 
either of inflammatory action or of organic disease ; 
sometimes similar efl'usion exterior to the substance of 
the brain ; and in both cases much diminution of its size, 
and change of its form. 

Some general observations may be made here in re- 
gard to the symptoms attending and denoting this great 
variety of organic lesions within the cranium. 

1. A great variety of these lesions have certainly ex- 
isted, and probably for a length of time, in some cases, 
without causing any such derangement of the functions 
of the brain as attracted any attention; — certainly without 
causing so decided derangement of these functions as 
has often been observed in cases where, on dissection, 
no morbid alteration of structure could be detected. 

2. In a much greater number of cases these organic 
lesions, as well as those which result directly from in- 
flammation within the head (^. e, eff'usion of serum and 
of lymph, abscesses, yellow or red softening of the cere- 
bral substance), have been found connected with de- 



684 OUTLINES OF PATHOLOGY AND PRACTICE. 



rangement of some department of the functions of the 
Brain and Medulla oblongata — of Sensation, of Thought, 
or Voluntary motion ; but the seat of the lesion has no 
ascertained connexion with the^, function deranged, far- 
ther than this, that any paralytic symptom is generally 
in the opposite side from the affected part of the brain, 
and that a lesion near to the origin of a nerve may be 
expected to affect the function of that rather than of a 
distant nerve.* 

. 3. Th€ symptoms found in connexion with these or- 
ganic lesions of the brain are sometimes quite chronic, 
and nearly unchanged for a great length of time, e. g. 
constant dull pain of head, intractable nausea and vo- 
miting, palsy of one side of the body, or of a single limb, 
loss of memory general or partial, insanity general or 
partial, or even partial or total imbecility or fatuity. 

4. In other cases, such organic lesions are found in 
connexion with violent symptoms recurring only occa- 
sionally, and leaving intervals, either of perfect health, 
or of some of the less violent and more permanent affec- 
tions of the nervous system ; e. g, with fits of epilepsy, 
or with fits of transient insensibility without spasms, or 
with fits of mania, or melancholy. 

5. In other cases, these organic lesions are found after 
an attack of fatal coma, which may or may not have 
been preceded by febrile and inflammatory symptoms ; 
and those symptoms may either have supervened on 

* There are abundance of cases to shew, that no reliance can be 
placed on the supposed necessary connexion of disease of the ante- 
rior lobes with palsy of the tongue, or with loss of the memory of 
words, of the corpus striatum with palsy of the lower, or of the 
thalamus with palsy of the upper, extremity. 



CHRONIC DISEASES OF THE NEHVOUS SYSTEM. 685 



some of the more chronic diseases above mentioned, or 
occurred without previous ground for suspicion of cere- 
hyal disease. 

In many cases of organic disease within the head, 
there is a combination or succession of several of these 
sets of symptoms, acute or chronic, in the same person. ] 

In order to form some conception how so great va- 
riety should exist in the symptoms connected with these 
organic lesions of the brain, it is necessai'y to recollect 
the following principles : — 

1. Nervous matter may be totally unfit for its functions 
in the living body, although possessing quite its usual 
structure and appearance, at least to the naked eye, and 
although duly supplied with arterial blood ; as we learn 
from some cases of amaurosis, or of palsy, unconnected 
with any perceptible alteration of the nerves or brain ; 
and again, nervous matter may undergo considerable 
change of form and appearance, if slowly and gradually 
effected, and nevertheless continue to perform its func- 
tions ; as we learn particularly from some observations 
on diseases of the spinal cord. From these facts it evi- 
dently follows, that parts of the brain apparently some- 
what diseased may still be susceptible of the changes 
which attend the exercise of sensation or thought ; and 
again, that portions of nervous matter may be disqua- 
lified for their functions by such organic diseases, al- 
though there be no obvious lesion of them, or although 
they be situated at some distance (and in various direc- 
tions) from those which are the most obviously diseased. 
And in fact, we know from Physiology, that it is only 
by deranging the functions of nervous fibres at some dis- 
tance from itself, that any lesion of parts, superior to the 
medulla oblongata, can cause either palsy or convulsion. 



686 



OUTLINES OF PATHOLOGY AND PRACTICE. 



2. Any such organic disease must necessarily confine 
and disturb the circulation within the head, and there- 
fore will necessarily act as a predisponent cpaise of those 
diseased states which may be excited, either by sudden 
determination of blood to the head, or by sudden dimi- 
nution of the flow of blood thither ; — which causes are 
certainly often concerned in producing the more tem- 
porary diseases connected with these organic affections 
in the brain. 

3. Such organic affections must also evidently act as 
a great predisposing cause of inflammatory action within 
the cranium, which may be generally supposed to have 
occurred, not only when decidedly inflammatory effusions 
are found, but whenever there is reason to believe that 
a rapid serous effusion has taken place, especially if pre- 
ceded by violent pain and febrile symptoms. 

It will readily be understood, that it is chiefly by the 
great predisposition given to these more acute diseases, 
that the organic lesions of the brain produce fatal coma ; 
although in some cases, the more chronic and uniform 
symptoms which they excite pass insensibly into coma 
without inflammatory symptoms, and without any effu- 
sions that can be ascribed to inflammation appearing on 
dissection. 

The contents of the canal of the vertebra?, and the 
nerves, are liable to organic lesions corresponding to 
those described in the contents of the cranium, and with 
similar effects, often well marked, but likewise variable, 
on the functions of the spinal cord and nerves : perhaps 
the most common is the chronic softening or chronic 
hardening of the medullary matter. We can under- 
stand, from what has been stated as to the effects of fatal 
injuries of the nervous system, that when the spinal 



OF APOPLEXY AND PALSY. 



687 



cord is extensively and seriously injured by disease, the 
organs of circulation should be gradually enfeebled, and 
that death may ensue apparently from this cause, in- 
dependently of the accession of coma ; and likewise that 
tumours growing within the sheaths of nerves, and 
separating their fibres, should cause intense pain (liable, 
however, to remarkable remissions), whatever be their 
own nature. 

Certain of the organic lesions of the brain are no 
doubt liable to absorption, as that which results from 
haemorrhage has been described to be ; but we can have 
little expectation of any of them being much changed in 
this way, particularly when they are of the kind de- 
scribed as constitutional or even malignant ; and there- 
fore the main principles we must hold in view in regard 
to them are those which have been already stated, viz. 
1. That many of them may exist in a certain degree, 
and for a long time, without any serious consequence 
resulting ; and 2. That when such consequence does re- 
sult, it is very often immediately excited by some cause 
deranging in one way or another the circulation in the 
brain and medulla oblongata, and the effect of which 
will bear some proportion to the degree of that de- 
rangement. 



Sect. II. — Of Apoplexy and Palsy, 

It may be judged, from what has been repeatedly 
stated, that the Apoplectic state may occur from various 
causes, and in very different states of the system ; but it 
occurs most frequently as an idiopathic disease, when 



G88 OUTLINES OF PATHOLOGY AND PRACTICE. 



we have reason to believe it to depend either on conges- 
tion of blood or bsemorrbage in the brain. 

Such cases occur most frequently in those who have 
lived fully, especially if they have taken little exercise, 
and become plethoric, — in those who are advanced in 
life, — in those who have a hereditary disposition to the 
disease, — in those in whom the head is large and the 
neck short, — in those who have organic disease of the 
heart, obstructing the circulation there, — and remark- 
ably in those, in whom a previous attack of the same 
disease has occurred. 

The disease occurs, however, in many persons who 
have not these peculiarities ; and it is easy to perceive 
that those who have a diseased state of the arteries must 
be liable to it, whatever be their constitution in other 
respects. This is indeed the chief cause of the frequency 
of the disease in connection with dilatation, or hyper- 
trophy of the heart. 

In those who are predisposed, it is excited by any of 
the causes mentioned as deranging the circulation, and 
causing irregular determinations, — by violent muscular 
exertion, particularly with straining, — by strong mental 
emotion, particularly anger or vexation, — by exertions 
of voice, fits of coughing, &c. — very often by exposure 
to cold, checking the circulation on the surface, — and by 
suppression of accustomed evacuations. 

It is often preceded, and a warning given of its ap- 
proach, by various uneasy sensations, or temporarily dis- 
ordered actions, of sense or voluntary motion, to which 
it is of the utmost importance for those who have any 
such, predisposition to attend, particularly headache, fits 
of giddiness, often attended with nausea, temporary fits 
of blindness, dimness of sight, or suffusiones, or double 



OF APOPLEXY AND PALSY. 



689 



vision, tinnitus aurium, temporary numbness or loss of 
power over some limb^ or transient loss of memory or 
confusion of thought. 

The amount of disturbance of the functions of the 
brain, in an apoplectic attack, which may be followed by- 
palsy, is exceedingly various, from transient loss of 
speech, or of recollection, or of power over a few mus- 
cles, up to perfect Coma;, which may be fatal within an 
hour, and is often fatal in a few hours. 

In some cases, there is first a sudden and temporary loss 
of sense, and of voluntary power, with depression of the 
heart's action, coldness and paleness, — then a recovery 
from this state, and, within a few minutes more, a gra- 
dual accession of coma, which in such cases is uniformly 
fatal. It was first observed by Dr Abercrombie, that 
as the succession of symptoms in such cases is exactly 
similar to that in persons who have received an injury 
and concussion, and had a bloodvessel ruptured within 
the cranium ; so the appearances on dissection, in cases 
which have run this course, are just similar to those 
found after such injury, viz. extensive effusion of blood, 
generally either in the ventricles, or at the base of the 
brain. 

There are many varieties as to the extent, and degree, 
and duration of the insensibility, and the affection of the 
mental faculties, in an attack of apoplexy, or sudden 
coma. It may easily be supposed that the symptoms 
indicating the most immediate danger, are those which 
•denote that the muscular actions of Respiration are 
affected, — the slow, noisy, stertorous breathing, — the 
irregular or interrupted breathing, — the puffing of the 
cheeks in expiration,— and ultimately what is generally 



4 



690 OUTLINES OF PATHOLOGY AND PRACTICE. 



the last change, the rapid and laboured, but obviously 
imperfect expansions of the chest. 

The pulse is variously affected, — often it is slow and 
full, — often varying somewhat with the changes of the 
respiratory actions ; in many cases a distinctly febrile 
paroxysm sets in soon after the stroke, which may al- 
ways be suspected to be connected with the inflamma- 
tion to be apprehended about a clot of blood effused in 
the brain. 

It is always to be apprehended that this state of 
apoplexy will be followed (as indeed it may often be ob- 
served to be attended) by loss of sense, or of voluntary 
motion, or both, in some part, generally one side of the 
body ; and likewise with some degree of loss of recol- 
lection, and of weakness of intellect, particularly of a 
tendency of the mind to dwell on particular thoughts, 
and to have emotions easily excited, and easily affecting 
the body. 

There is no fixed proportion between the degree, or 
duration of the insensibility, and the extent of palsy 
that follows, or the speediness or completeness of the 
recovery, which is always gradual, and almost always 
begins in the lower extremity, sooner than the upper. 

When the palsied limbs are found contracted or af- 
fected with Tonic Spasm, — especially if some degree of 
fever be present, there is much reason to suspect that 
inflammatory softening of the brain has supervened, 
and therefore, that although a certain degree of im- 
provement may have taken place, the patient will re-* 
lapse into coma ; in these circumstances, attended with 
extreme danger. 

If this do not occur, there may be gradual and uiti- 



OF APOPLEXY AND PALSY. 



G9i 



mately nearly complete — hardly ever absolutely com- 
plete — restoration of tlie powers of sense and voluntary 
motion, and of the natural state of the mind ; but in 
many cases, partial palsy, or partial mental aberration 
or idiotcy, or partial loss of memory, e. g. of the me- 
mory of words, or more peculiarly of the memory of 
substantive nouns, remains for a long time, or for life. 

The bowels are generally costive, and moved with 
difficulty by medicine, during, and after the apoplectic 
state ; the affection of the bladder is more various ; in 
bad cases there is generally retention of urine at first, 
which is apt to be followed, as in other cases, by incon- 
tinence. 

Although there be complete Hemiplegia, the actions 
of Respiration are performed perfectly on the palsied 
side of the body, as is easily understood when we re- 
member, that the impulse to these actions comes only 
from the medulla oblongata, whereas the cause that im- 
pedes the action of the will, lies very generally higher 
than this in the brain. In like manner, we can un- 
derstand that such indications of the reflex action of the 
spinal cord, as are not necessarily attended with sensa- 
tion (as e. g. on tickling the soles of the feet), should 
take place in the palsied limbs, — often indeed with unu- 
sual intensity ; — and that such motions as. are excited 
only by sensations, e. g. stretching the limbs in the act 
of yawning, should be observed, while those limbs are 
quite palsied to the will. 

When the cause of palsy lies in the medulla oblongata, 
or spinal cord, the respiratory motions are usually sus- 
pended, so far as they depend on the motor nerves arising 
below the injured part j but it would appear from a few 
cases, that although the motor portion of the spinal cord 
in the neck has lost its power, and the body is incapable 



692 OUTLINES OF PATHOLOGY AND PRACTICE. 

of voluntary effort, if tlie sensations are entire, the respi- 
ratory actions can go on ; which seems manifestly to 
imply, that the nervous action excited by the impulse to 
breathe, may pass downwards along the posterior portion 
of the cord, and cross to the anterior, so as to excite the 
motor nerves concerned in this action, at different parts 
of the cord. 

The state of apoplexy may be produced, and be fatal, 
Without any effusion of blood, or other morbid ap- 
pearance, shewing itself in the brain, to which cause the 
term Simple Apoplexy has been applied. We have 
reason to think, however, that in the greater number of 
such cases, the cause of the apoplectic state is the pres- 
sure exerted on the brain, by an increased propulsion of 
blood upon it, or transmission of blood through it ; — not 
so much on account of the indications of such determi- 
nation of the blood, visible on dissection (which w^e re- 
gard as equivocal) as on account of the reasons stated 
formerly (p. 554-6, et seq). 

This is probably the cause of most of those attacks 
of apoplexy, occasionally occurring, from which the pa- 
tients recover perfectly; and there are also cases,— 
chiefly in persons of that habit of body, which is de- 
scribed under the name of Mobility of the Nervous 
System, — in which absolute coma occurs as a strictly 
functional disease, without the application of any known 
cause. Of this the most striking examples are in the 
cases on record, of long continued stupor, occurring 
chiefly in women, and described under the name of Hys- 
teric Coma, from which there may be speedy and per- 
fect recovery. 

The sudden attack of apoplexy above described, fol- 
lowed by Hemiplegia, is almost always the result of 
effusion of blood on the brain, and the consequences 



OF APOPLEXY AND PALSY. 



693 



thence following which were formerly described, and has 
been generally termed Sanguineous Apoplexy. And 
there are many cases more gradual in their attack, ge- 
nerally abating and recurring repeatedly, and leaving 
behind them either no palsy, or more partial palsy, a 
more variable affection of the mind, and often a variety 
of other nervous disorders, such as were specified above 
(p. 684), — to which the name of Serous Apoplexy has 
generally been given ; and in many of which, serous effu- 
sion has been found on dissection, but in many others, 
either more une'|uivocal indications of chronic inflam- 
mation, or some of the kinds of organic disease formerly 
described. 

In a few cases of palsy, with more or less of comatose 
tendency, it has appeared, on dissection, that the cause 
had been just the opposite of the more usual condition, 
viz. such an obstructed state of the arteries, leading to 
part of the brain, as must have nearly deprived that 
portion of its supply of blood. 

There are cases of Paraplegia, as well as more par- 
tial palsy, which come on gradually, after threatenings 
or attacks of apoplexy, and some of these have ap- 
peared, on dissection, to be connected with some such 
morbid appearances as those now mentioned, in the brain ; 
but in the greater number of cases of Paraplegia, the 
senses and the mind are unaffected, and the cause of 
the disease, whether inflammatory or organic, or, in a 
few cases, hasmorrhagic, is evidently in the spinal cord. 

There are also cases of more partial palsy, which ap- 
pear on examination to depend on local causes, some- 
times inflammation, often organic disease, affecting in- 
dividual nerves only. Of this the palsy, either of the 
facial nerve {i.e. the motor nerve of the cheek, hps, 

PART III. Y y 



694 OUTLINES OF PATHOLOGY AND PEACTICE. 

and eyelids), or of the fifth pair (i. e, the sensitive nerve 
of tlie face, and motor only of the elevators of the lower 
jaw), are examples familiar to us since their nature was 
pointed out by Sir Charles Bell. 

And there are also cases of palsy, the cause of which 
probably resides in the muscular fibres themselves 
being wasted and attenuated, rather than in any change 
in their nerves ; particularly the palsy from rheumatism, 
and that from the poison of lead. 

Apoplexy is one of the cases in which the most im- 
portant part of the practice that we can employ is di- 
rected, not against symptoms that we see, but against 
those which we apprehend to be approaching. In the 
persons who are predisposed to the disease in the ways 
above stated, and who have suffered any of the threaten- 
ings of its approach above enumerated, a careful regi- 
men ought always to be prescribed, such as may obviate 
plethora, and diminish the tendency to determinations 
of blood to the head ; and by such a regimen we have 
good reason to believe that many attacks of the disease 
may be prevented. This regimen may be said to be a 
combination of the strictly antiphlogistic with some 
part of the tonic, and consists chiefly of the following 
particulars :— 

1. A light and spare diet, consisting chiefly of the 
more nourishing and least flatulent kinds of vegetable 
food, with only a moderate quantity (varying somewhat 
according to the degree of plethora, and the age and 
habits of the patient, and urgency of the symptoms) of 
animal food, simply dressed, and without fat, taken at 
dinner time only. Spirituous liquors are too stimulat- 
ing, and the stronger malt liquors, as favouring plethora, 



OF APOPLEXY AND PALSY. 



695 



should be entirely prohibited ; and wine and tlie weaker 
malt liquors either proscribed altogether, or allowed in 
small quantity only, as the state of the circulation, and 
of the assimilation of food, may demand. 

2. Regular and early hours both of taking food and 
sleep ; and abridgment of the time spent in sleep. 

3. Shaving or close cropping of the hair, and fre- 
quently washing the head with cold or tepid water. 

4. A regularly open state of the bowels, secured 
partly by vegetable diet, and partly by the frequent use 
of mild laxatives. Those which act likewise on the 
skin, particularly such as contain small quantities of 
antimony and ipecacuan, are thought by some the most 
appropriate. 

5. A great deal of regular moderate exercise in the 
open air, secured by the inducement of any interesting 
occupation, but never carried so far as to cause fatigue, 
nor so violent as to cause strono- excitement. 

6. Care to avoid any exposure to cold or wet, parti- 
cularly such as may cause chilling of the extremities. 

7. Care to avoid any such external heat as may sti- 
mulate the circulation, e. g. cool airy rooms, a firm mat- 
tress and pillow, on which the head and shoulders should 
be much raised during the night. 

8. Mental tranquillity, or gentle excitement only. 
On occasion of a sudden and decided threatening, by 

any of the symptoms above mentioned, the proper re- 
medies are, bleeding, particularly local bleeding, purging, 
and a very low diet for a few days. 

The remedies to be employed during a fit of apoplexy 
are few and simple. They are — 

1. Full, and generally repeated, bleeding from the 
arm, which we should regard as contra-indicated, in this 



696 



OUTLINES OF PATHOLOGY AND PEACTICE. 



case, not by the age, oi- apparently feeble previous habit 
of the patient, but solely by the indications, sometimes 
observed, of failure of the circulation. 

On the other hand, when the insensibility is abating 
and the palsy remains, the indications for further bleed- 
ing are in the state of the pulse, and perhaps pain of 
head, not in the other affections of the brain, which 
must be expected to abate very slowly. 

2. Full purging, for which purpose the Croton Oil, or 
other purgatives in small bulk, are the most proper, and 
which may in general be repeated much more frequently 
than the bleeding. 

3. Cold applications to the head, which should be 
shaved and kept high, while the extremities are kept 
warm, and all ligatures or tight dress removed. 

These remedies are used with the intention of restrain- 
ing the flow of blood to the injured part of the brain, 
preventing fresh effusion, and checking the inflammation 
which is to be expected from effused blood ; and their 
repetition must be directed chiefly by the urgency of 
the symptoms denoting that inflammation. For a con- 
siderably longer period, the strict antiphlogistic regimen 
should be directed, unless the state of the pulse should 
demand the cautious use of stimuli ; and this regimen 
should be gradually exchanged for the somewhat more 
tonic one above described. 

The state of palsy succeeding to an apoplectic attack 
admits of no useful treatment except gentle, gradually 
increasing, exercise of the affected limbs, and frequent 
frictions. In some instances, at a later period, gal- 
vanism passed through them, or the effect of strychnia, 
taken cautiously in such quantity as to cause twitching 
of the limbs, has appeared to accelerate the return of 



OF APOPLEXY AND PALSY. 



697 



tlie power ; but, in other instances, even over-doses of 
the strychnia, such as obviously implied temporary dan- 
ger, have had no effect whatever on the patient's limbs. 

The effect of such expedients is probably greater in 
cases where the palsy is only partial ; and especially 
when it is dependent on the state of the muscles, rather 
than of the Nervous System. 

When we have reason to suppose, from the frequent 
recurrence of slight fits, or from the urgency of uneasy 
sensations, as fixed pain, vertigo, nausea and vomiting 
(sometimes almost the only symptom), dimness of sight, 
&c. without febrile symptoms, that some organic dis- 
ease is slowly making progress, the only additions to the 
practice above stated which we can recommend, are an 
issue or seton in the neck, and a course of Mercury, cau- 
tiously employed, lest it produce an irritating effect on 
the brain, or a long continued course of preparations of 
Iodine in small doses. 

Frequently there are dyspeptic symptoms or other in- 
dications of failure of the general strength, which may 
demand remedies, particularly bitters or chalybeates, du- 
ring the paralytic state ; sometimes there is such restless- 
ness as makes it necessary to use some of the Narcotics — 
Hyoscyamus, Conium, or even Morphia, in combination 
with laxatives ; and in the advanced stage of many cases, 
particularly when softening of the brain has occurred, 
there are such typhoid symptoms, and such gangrenous 
sores from pressure, as demand the cautious use of wine. 

It was formerly stated, that in children a state very 
nearly resembling the coma of Hydrocephalus sometimes 
occurs as a consequence of much evacuation, particularly 
of diarrhoea, and abates in some cases under the use of 
stimulants and astringents, In like manner, in adults, 



698 OUTLINES OF PATHOLOGY AXD PRACTICE. 



after long-continued discharges, e. g, by Piles, symptoms 
sometimes occur nearly akin to those which usually re- 
sult from increased determination of the head, and pre- 
sage apoplexy, e, g. headaches, giddiness, dimness of 
sight, tinnitus aurium, all which, in such circumstances, 
admit of relief from stopping the discharges, and from 
a fuller diet, and the cautious use of stimuli. 

Sect. III. — Of Spasmodic Diseases. 

The diseases which can be distinctly referred to this 
head are the following : — 

I. The term Convulsion is generally applied to a fit 
of general spasms, with insensibility, occurring in the 
course of another disease {e. g, of Fever, Hydrocephalus, 
or Hooping-Cough), or proceeding from a known cause 
of irritation, affecting the Nervous System, such as teeth- 
ing or worms, or the pains of labour, " ab irritatione ma- 
nifesta orieus, et ablata irritatione cessans j" and when 
similar fits occur idiopathically, and without such known 
irritation, and especially when they occur repeatedly 
without obvious cause, and therefore constitute a disease 
in themselves, the name Epilepsy is usually applied ; and 
although this use of the terms is not in accordance 
with the definitions of Cullen, as it has become gene- 
ral, and is not liable to serious objection, it may be re- 
tained. 

The symptomatic convulsions in the course of various 
diseases, or occasional convulsions, excited by a reflex 
action, from teething, or from any irritation affecting 
the mucous membrane of the alimentary canal, — are 



OF SPASMODIC DISEASES. 



699 



much more common in infants and children than in 
adults; and we have many cases in such young subjects 
likewise, of habitually recurring convulsions, with in- 
sensibility, not traced to any such single cause, but to 
which the term Convulsion is more generally given than 
that of Epilepsy ; but when children, after the time of 
the second dentition, become subject habitually to such 
attacks, this last term is generally applied. At all periods 
of life such convulsions may be produced by certain 
causes directly affecting the brain or spinal cord, — by 
mechanical injury, sudden haemorrhage, or the action of 
certain poisons. 

In the perfect form of Epilepsy the attack is as sud- 
den as that of Apoplexy, the duration of the spasms 
very various, but the insensibility always continues some 
time longer, — the recovery of the power over the muscles, 
and of the Senses, is complete, no palsy following ; — but 
the recovery of recollection is more gradual, and after a 
certain number of recurrences the memory is in general 
permanently impaired. 

There are many varieties, however, in regard even to 
the well-marked epilepsy. In a few cases the fits of 
convulsion, at least the earlier fits, are without insensibi- 
lity to surrounding objects ; in a greater number there are 
fits of insensibility, repeatedly recurring, followed by no 
palsy, but unattended with spasm : in some cases the 
spasms are partial, and the insensibility lasts only a 
few minutes or even seconds, but the recurrences are 
frequent, several in a day, or even in an hour ; in others 
the fits are long and profound, but the recurrences are 
at intervals of many weeks or even months : in some 
cases, transient fits of delirium, or of jactitation, take 
the place of regular epileptic fits ; and are equally ef- 



700 OUTLINES OF PATHOLOGY AND PRACTICE. 



faced from tlie recollection immediately afterwards. 
Some cases evidently graduate into the slighter spasmodic 
diseases, Hysteria and Chorea, while others are from the 
first, or gradually hecome, combined with the different 
forms of Insanity. 

In some cases of Epilepsy there are distinct premoni- 
tory symptoms, either a short time previously, or im- 
mediately preceding the paroxysm, — slight fits of deli- 
rium, or loss of recollection, — transient difficulty of ar- 
ticulation, — partial spasms, — screams or sobbing, — 
flashes or sufFusiones before the eyes, — coldness of the 
extremities and flushing of the face, — or the peculiar 
sensation called Aura Epileptica, moving upwards from 
one of the extremities to the head. 

In many cases, particularly the less violent, the fits 
come on only during sleep, or at least only in the recum- 
bent posture. 

Observation of the history of this disease shews that 
the following are the chief predisponent causes to which 
it may be ascribed. 

1. Hereditary peculiarity, the efficacy of which has 
sometimes been strikingly seen in cases where a parent 
has become epileptic {e. g. from an injury), and the dis- 
ease has been transmitted to those of his children only, 
who were born subsequently to that occurrence. 

2. Fulness of blood. 

3. A certain mobility or irritability of constitution, 
existing in infants and children, and in women at the 
time of menstruation. 

4. Previous disease of the heart. 

5. The facility given to this or to other inordinate 
muscular motions, by their own repeated excitation. 

And morbid anatomy teaches, that although there 



or SPASMODIC DISEASES. 



701 



are many cases of predisposition, and even of hereditary 
predisposition, for wbicli we cannot assign a reason, yet 
in many cases the predisposition is given by one or other 
of the following peculiarities, visible on dissection. 

1. Malformation, or irregular growth of some of the 
bones of the head. 

2. Organic disease, of some one of the kinds formerly 
noticed, in the brain or its membranes. 

3. Organic disease of the heart, particularly such as 
impedes the descent of blood by the superior cava, and 
through the right side of the heart. 

In those thus variously predisposed to the disease, 
many of the paroxysms are distinctly seen to be excited 
by causes either acting directly on the brain or spinal 
cord, or disturbing the circulation ; particularly, 

1. Injury of the head or general concussion of the 
body — electricity — intense heat. 

2. Violent muscular exertion. 

3. Strong mental excitement or emotion. 

4. Intemperance, either in eating or drinking. 

5. Venereal excesses. 

6. The sudden suppression of any usual evacuation, 
as that of Porrigo in children, or of Haemorrhoids, or of 
any chronic cutaneous disease, in adults. 

7. Intense pain, as from wound of a sensitive nerve. 

8. Large haemorrhage, or other cause of sudden 
syncope. 

It may be easily understood from what was stated as 
to the effects of different violent and fatal injuries, in 
producing convulsions, that Epilepsy may be excited 
either by causes of Apoplexy or by causes of Syncope. 

There are many instances of the communication or 
propagation of Epileptic fits by Imitation, although that 



702 



OUTLINES OF PATHOLOGY AND PEACTICE. 



is more especially observed of the slighter spasmodic af- 
fections next to be mentioned ; and it is probably only 
in those peculiarly predisposed to it that the perfect 
Epileptic paroxysm is produced in this way. 

It is obvious, that when organic disease of the brain or 
cranium is found on dissection in persons long subject 
to Epilepsy, some temporary and occasional cause must 
have co-operated with the permanent predisposition, 
each time that the temporary spasms supervened on the 
organic disease. And although there are many pa- 
roxysms which cannot be traced distinctly to the action 
of any of these exciting causes, yet we cannot doubt that 
many may be prevented, and their injurious conse- 
quences on the bodily health, on the mental faculties, ^and 
on the facility of reproduction of the disease, be avoid- 
ed, by precautions to avoid these exciting causes. 

The absolute disappearance of the disease, however, 
after it has been well marked, is seldom observed, — more 
frequently in the Epilepsy of children under the age of 
puberty, and who become free of it at that time, and in 
the Uterine Epilepsy, recurring only at the menstrual 
periods, than in any others ; evidently because the pecu- 
liar mobility of constitution stated above as the chief 
circumstance of predisposition in these cases, is less per- 
manent than the other predisposing causes above enu- 
merated. . 

But we have no doubt, that, by proper management of 
the disease, the frequency of its recurrence may gene- 
rally be diminished, and its transition into other more im- 
mediately dangerous states of the Nervous System be 
often averted. 

The occasional attacks of Convulsion from obvious 
causes, although attended with more immediate danger 



OF SPASMODIC DISEASES. 



703 



than single paroxysms of habitual epilepsy, admit often 
of more decided benefit from remedies, both from deple- 
tion by bleeding and purging, and from removal of the 
cause of irritation; as, e. g,, those dependent on teething, 
from scarifying the gums, —those dependent on Lumbrici, 
from effectual Anthelmintics, — those dependent on other 
irritations acting on the bowels, from the full action of 
Cathartics ; those dependent on child-bearing, from as- 
sistance to accomplish that act. A few cases, depend- 
ent on suppression of urine by incipient granular disease 
of the kidneys, have been effectually relieved by full 
bloodletting. 

The paroxysms of the disease are sometimes, particu- 
larly soon after they have commenced, attended with 
much frequency and fulness of pulse, and signs .of de- 
termination to the head ; and in such cases full bleed- 
ing and other measures of depletion and derivation, as 
in apoplectic cases, are demanded, and may probably 
sometimes prevent fatal coma : the convulsions of puer- 
peral women are a good example of the danger now in 
view, and of the importance of full bleeding to arrest 
it : but in the progress of the habitual epilepsy, the pa- 
roxysms are attended with less or less permament dis- 
turbance of the circulation, and large depletion becomes 
injurious, as increasing the mobility of the Nervous Sys- 
tem, or even in some cases directly exciting the fits. 

Tt is obvious, however, that of the circumstances 
of predisposition above stated, fulness of blood is that 
which is most under our power, and, accordingly, it may 
be stated with confidence that in plethoric persons, or 
even in those of average fulness, a diet almost entirely 
vegetable, and absolute abstinence from strong liquors, 
along with much habitual exercise in the open air, is 



704 OUTLINES OF PATHOLOGY AND PEACTICE. 



more effectual than any thing else, in diminishing the 
frequency and violence of the paroxysms. 

By these means, by a tranquil mode of life and care- 
fully avoiding the exciting causes of the disease, and by 
the regular action of laxatives on the bowels, it may be 
supposed that the growth of organic diseases in the 
cranium may be restrained, and many occasional and 
dangerous determinations to the head be averted. But 
in weakly persons, and in the more advanced stages of 
the disease, there is often no plethoric tendency, and the 
disease is obviously more dependent on mobility of the 
nervous system : and besides exercise, other parts of the 
tonic regimen become more important, particularly tepid 
or cold bathing (with precautions against chilling of the 
extremities), and even a somewhat fuller diet. 

In all cases, precautions against local Plethora, wash- 
ing of the head, a cool bed-room, and a high and firm 
pillow, are important ; and in some the evacuation of a 
seton or issue in the neck has been obviously beneficial. 

It seems well ascertained, that various medicines pos- 
sess a certain degree of power in correcting that excit- 
able condition of the Nervous System which we regard 
as constituting a part of the predisposition to Epilepsy ; 
but the degree of this power is very generally quite in- 
adequate to counteract any but the slightest cases of this 
disease. In the milder and incipient cases, particularly 
those marked as admitting the best prognosis, it is 
right to give them a fair trial ; but in inveterate cases, 
if they are used at all, it should be understood that no 
reliance can be placed on their efncacy. Those vrhich 
have appeared the most useful, although with varieties 
as to their power, which we can refer only to peculiari- 
ties of constitution, are the following ; Valerian, Bark 



OF SPASMODIC DISEASES. 



705 



or Quinine, and Indigo, in full doses, often best used 
when combined with small doses of laxatives, — the Oil 
of Turpentine in frequent small doses, — the Nitrate of 
Silver, the Ammoniuret of Copper, the Oxide or Sul- 
phate of Zinc, and the Arseniate of Potass, — all in small 
but gradually increasing doses. 

II. There is a large class of Spasmodic Affections, 
which would appear to originate in morbid action of the 
motor nerves, and of the parts within the spinal canal 
and cranium immediately connected with them, but 
which seem never to depend either on inflammation or 
organic lesion of these parts, or even on vascular con- 
gestion there, as an essential condition, although it may 
often be an aggravation, of their existence. These spas- 
modic diseases may in general be distinguished from 
those which depend on the effects of inflammation, or of 
organic disease, by their being unattended ivitJi insensi- 
bility ; and indeed, in several of these, the spasms may 
be said to denote rather a perversim of Voluntary Mo- 
tion than strictly Involuntary Motion. 

Of these Spasmodic Diseases, unattended with coma, 
there are three divisions, obviously distinguished from 
one another. In the first it is confined to certain of the 
muscles concerned in respiration, and being always at- 
tended with inflammation, of greater or less violence, in 
the mucous membrane of the air-passages, has been al- 
ready under consideration. In the second, the affection 
of the voluntary muscles is general and irregular, but 
chronic, and seldom dangerous ; in the third it is equally 
general, but much more acute and violent, and attended 
with very great danger. 

The only addition to be made to the first of these 



706 OUTLINES OF PATHOLOGY AND PRACTICE. 

divisions of diseases, of which Asthma and Hooping- 
Cough are the chief, is the mention of the Laryngismus 
stroduhis, or crowing disease, most frequent in children, 
but also seen in adults, which is a spasm of the muscles 
of the glottis. Sometimes idiopathic, at other times 
symptomatic, already considered, and often admitting 
of relief in like manner as other spasmodic diseases. 

The second of these divisions comprises a number of 
cases, in which the spasms vary so much, that it is im- 
possible to rank them together under one general de- 
scription ; but the most definite cases of the kind are 
the following. 

a. The disease called Chorea is characterized by in- 
voluntary motions of one side of the body, increased by 
attempting any definite movement, and attended by 
much weakness of the lower extremity of that side, 
which occur chiefly between the ages of ten and four- 
teen, and often abate entirely, under various treatment, 
within a few months ; in some instances, however, going 
on, either to permanent amentia, or to fatal hydroce- 
phalus. 

In such cases, this disease must depend, in part, on 
organic disease of the brain ; but the favourable result 
of the great majority of cases of the disease shews that 
it cannot have depended on any permanent alteration of 
structure. In some cases of this disease, as in the prac- 
tice of Sydenham, bloodletting has seemed effectual ; 
in others, as in that of the late Dr Hamilton sen., long- 
continued purging has been distinctly beneficial, particu- 
larly where the appearance of the evacuations has shewn 
previous retention and accumulation ; in others, counter- 
irritation along the spine has seemed more useful ; in 



OF SPASMODIC DISEASES. 



707 



others, what has been called the tonic plan, the tepid 
and cold shower-bath, and full doses of carbonate of 
iron, or gradually increasing doses of oxide of zinc, or 
of arseniate of potass, have been successful ; and it must 
always be remembered, that in some, where several of 
these measures had been ineffectual, the disease has 
spontaneously subsided, particularly under the influence 
of country air and summer v/eather. 

h. The name of Hysteria is properly given to fits of 
Convulsion, affecting many parts of the body, but com- 
mencing generally with uneasy feelings in the abdomen, 
and with the sensation called Globus, ascending thence 
to the throat, and exciting a spasm of the glottis : it 
differs from epilepsy in being unattended with insensi- 
bility ; in the paroxysms being more generally excited 
by some evident cause, and recurring often more fre- 
quently within a short time, but much less pertinaciously 
throughout the life of the patient : — it is hardly ever 
seen in the male sex, and admits of a very great variety 
as to the nature of the spasms, the frequency of their 
recurrence, the other affections of the nervous system, 
and of the secretions of the body attending it, and also 
as to concomitant affections of the vascular system, the 
pulse being full and firm, and evacuations of blood use- 
ful in some cases, while in others there is great weak- 
ness, and advantage from stimulants. 

The variety as to the symptoms and history of the 
disease is in fact such, that there is hardly any other dis- 
ease, the symptoms of which may not be imitated, more 
or less exactly, in persons liable to hysteria, by affec- 
tions which are simply nervous, and which are evidently 
akin to hysteria, and are generally designated by that 



708 OUTLINES OF PATHOLOGY AND PRACTICE. 



name. Thus symptoms nearly resembling those of in- 
flammation of the parietes of the chest and the stomach, 
or peritonaeum, — tympanitic distension in all degrees, — 
violent and obstinate palpitations, sometimes attended 
with slight bruit ^ — violent headaches, or other local 
pains, — tetanic or other partial spasms, or fits hardly 
distinguishable from epilepsy, — partial palsy, especially 
paraplegia, and retention of urine, — occasional fits of 
delirium, or of partial hallucination, — even perfect coma, 
sometimes of long-continuance, may occur in hysterical 
patients, especially when aftected with amenorrhoea, or 
irregular menstruation ; and, — in some cases by careful 
observation of the attending symptoms themselves, in 
others by cautious trial of remedies, and in many by the 
rapid and favourable event of the case, particularly if 
the menses shall be restored, — may be proved to depend 
neither on inflammation nor permanent disorganization 
of the nervous matter. Thus also violent fits of cough- 
ing, or of vomiting, dependent on peculiar sensations, 
which seem to reside in the nervous system only, with- 
out any indication of disease of the bronchise, lungs or 
stomach, are not uncommon in persons liable to Hysteria. 

Fits of Convulsion in children, without insensibility, 
as from teething, or from worms, or disordered bowels, 
are often more analogous to hysteria than to epilepsy, 
particularly as to their ultimate results. 

c. The rare, but well marked, and easily distinguish- 
ed, state of the voluntary muscles called Catalepsy, is 
that modification of spasm, in which the limbs retain 
any position in which they are placed ; a state never of 
lonof continuance, often combined with hvsteria, but 
which, as it evidently implies a perversion of the men- 



5 



OF SPASMODIC DISEASES. 



709 



tal act of volition, is generally excited by mental causes, 
and attended with more or less aberration of intellect^ 
forming therefore a part of strictly mental diseases. 

cl. Another set of cases of spasmodic disease, of this 
general character, have been described as periodical 
Jactitation, distinguished by the periodical recurrence of 
violent and. outrageous, but uniformly recurring, move- 
ments of the body or limbs, generally associated either 
with fits of Delirium, or with that state of mind to which 
the names of Reverie and of Somnambulism have been 
given.- 

Some general observations, of pra-ctical importance, 
may be made on the whole of this class of cases of spas- 
modic disorders, which are often the source of great un- 
easiness^ but, unless they become complicated with others, 
seldom dangerous ; and these observations apply also 
to the merely functional disorders of sensation, to be 
afterwards noticed* 

1. They are in many instances almost precisely simi- 
lar to the alterations of these functions which may result, 
either from chronic inflammation and its efi'ects, or from 
organic disease affecting the portions of the nervous sys- 
tem concerned in them. 

2. This analogy gives us reason to suspect^ that even 
when no organic lesion appears on dissection, such dis- 
orders may often proceed from imperceptible changes in 
the organization of the portions of nervous matter con- 
cerned. And accordingly we find, that these simply 
nervous disorders are most common in the same de- 
scription of persons, and under the same external cir- 
cumstances, as organic diseases ; they are more common 
in the inhabitants of tow^ns than of the country, more 

PAET III. z z 



710 OUTLINES OF PATHOLOGY AND PRACTICE. 



common in those whose lives are sedentary than in those 
who have much habitual exercise in the open air, more 
common in those in whom the nervous system has been 
habitually excited, by the artificial stimuli of civilized 
life, than in those in whom it has been habituated only 
to the ruder impressions of a life of labour ; several of 
them are more common in scrofulous than in sound 
constitutions, and probably all in the children of sickly 
than of healthy and robust parents. 

3. "When we have reason to think, particularly from 
the ultimate result of the cases, that these disorders 
have really no permanent cause in the structure of any 
part of the nervous system, we may observe that they 
occur only in certain individuals, and that in them there 
is that peculiarity of the actions of the nervous system, 
for which we have no more precise or definite ex- 
pression than Nervous Irritability, or Mobility ; — a 
state more common in women and children than in 
men, and in all persons when in a state of weakness, 
than when in the full enjoyment of muscular strength; 
in women, particularly, more common about the men- 
strual periods, and immediately after delivery, than at 
other times ; more common likewise in those whom the 
menstrual flux is habitually excessive, or altered, sup- 
pressed, or obstructed, than in others ; — in which state 
both sensations and emotions are intensely felt, and their 
agency on the body is stronger and more lasting than 
usual ; and continued voluntary efforts of mind, and 
steady or sustained exertions of the voluntary muscles 
are difficult or impossible, the muscular motions usually 
rapid and irregular, and the " animus, nec sponte, va- 
rius et mutabilis." When such a general condition of 
the functions of the nervous system exists, any portion 



OF SPASMODIC DISEASES. 



711 



of it, on whicli a special exciting cause may act, is apt 
to fall into a diseased mode of action more or less re- 
sembling that which inflammation or organic disease 
may excite in it. And it is farther of great importance 
to observe, that this tendency is greatly increased by 
each repetition of diseased action of this kind ; or even by 
any strong impression made by sensations or emotions on 
the bodily organs ; and therefore, that avoiding all occa- 
sions which can excite violent and nnpleasing sensations 
or emotions, is of essential use in correcting the ten- 
dency to such diseases. 

One modification of this nervous temperament, very 
frequently connected with its other marks, is the dispo- 
sition of the mind to dwell upon all uneasy sensations, 
and anticipate danger from them, which so frequently 
attends all diseases of which such sensations are an 
essential constituent, and especially disorders of the 
stomach and bowels, and to which we give the name 
of Hypochondriasis ; — which is chiefly observed in per- 
sons of the melancholic temperament, but not confined 
to them, and is more properly described as a condition 
of the mind, accompanying and aggravating many chro- 
nic diseases, than as a disease sui generis. 

Another mental affection, frequently attending such 
diseases, is the propensity to practise various impostures, 
and thereby excite interest and attention, formerly 
noticed. 

4. The nervous disorders in question, are easily ex- 
cited sympathetically by diseases of other parts of the 
system ; — not so much, however, by violent febrile or in- 
flammatory diseases, in which the circulation of the 
blood is much excited, as by those in which the secre- 
tions are much deranged, and many uneasy sensations 



712 OUTLINES OF PATHOLOGY AND PRACTICE. 



produced, without excitement of the circulation. Thus 
the symptoms of these disorders are very frequently 
combined with Dyspepsia in all its forms, with Consti- 
pation, and Diarrhoea, as well as with derangements of 
the Menstrual flux. 

5. These slighter spasms, and other nerrous affec- 
tions accompanying them, are the description of diseases 
most easily excited by mental emotion, especially in con- 
stitutions of the peculiar nervous irritability already 
describeti. Such affections, accordingly, in varied and 
sometimes in unusual forms, have very often been ex- 
cited by intense religious enthusiasm^ and often by the 
emotions excited by such applications as the metallic 
tractors (real or fictitious'), or the manipulations of those 
who profess animal magnetism. In all such cases, 
agreeably to facts known in Physiology, the emotions 
that may be excited are much heightened by the pre- 
sence and participation of numbers ; and these are the 
diseases which have been particularly observed to spread 
by Imitation, nearly after the manner of epidemics. 

The treatment of these functional disorders of the 
Nervous System, must be so much varied by the ever- 
varying circumstances of individual cases, that it can 
only be stated in very general terms. 

1. When they are connected with a vigorous and ex- 
cited state of the circulation, and particularly when 
they have occurred recently and suddenly, and from ob- 
vious exciting causes, they may be greatly relieved by 
depletion of all kinds, and antiphlogistic regimen ; but 
much or frequent depletion is to be avoided, as a cause 
which certainly increases the mobility of the Nervous 
System, 



OF SPASMODIC DISEASES. 



713 



2. On the other hand, when attended by an enfeebled 
state of the circulation, they may be decidedly benefited 
by the prudent use of wine and other stimuli, and more 
especially by a tonic regimen, gradually applied, of 
which probably the most important article is mental ex- 
citement, interest, and confidence, prompting to a gra- 
dual increase of muscular exertion, and withdrawing the 
mind from that minute attention to uneasy feelings, and 
morbid trains of thought, which is great part of the 
cause of these diseases. 

3. The slighter and earlier attacks of these diseases 
may often be relieved by the use of anodynes and other 
anti-spasmodics, opium, camphor, valerian, musk, assa— 
foetida, ammonia, &c. ; in some instances by the affu- 
sion of cold water, or other strong impressions on the 
organs of sense ; and, in cases of this kind, when the 
spasms are unattended with insensibility, there is not 
the same danger to be apprehended from opium, or 
other narcotics, as in Epilepsy, or move violent convul- 
sions ; but the continued use of all antispasmodic me- 
dicines, like the use of strong liquors, is ultimately in- 
jurious to the Nervous System, and destructive of the 
good effects first observed ; and, therefore, they cannot 
be used with permanent good effect in diseases which 
are essentially chronic. 

4. The medicines, therefore, which are most habi- 
tually useful in these diseases, are combinations of laxa- 
tives, with chalybeates, quinine, or other bitters, with 
which the tepid or cold shower-bath (according to the 
strength of the patient) may very often be conjoined. 
The laxatives are most useful in cases when morbid or 
accumulated excretions appear to be great part of the 
cause of the disease ; and, in like manner, stomachic 



714 OUTLINES OF PATHOLOGY AND PRACTICE. 



medicines in some cases, and emmenagogues in others, 
are the most effectual auxiliaries. 

The third order of those Spasmodic Affections, which 
seem to originate in morbid action of the nervou,s sys- 
tem itself, comprises the very dangerous disease called 
Tetanus, and the almost inevitably fatal one called 
Hydrophobia. The first, in a few cases, originates idio- 
pathically from cold, but is much more generally ex- 
cited by injuries, in which a portion of nerve has no 
doubt peculiarly suffered, although its injury is often 
imperceptible on examination. The disease does not 
commence, however, till some days after the cause has 
been applied ; and of the nature of the changes taking 
place in the interval we have no information whatever. 
It is characterized by violent painful Tonic Spasms, with 
frequent aggravations, but no absolute relaxation, be- 
ginning in the muscles of the hind neck and lower jaw, 
and extending over the whole muscles of the body ; it 
is unattended with any affection of the functions of the 
brain proper j and is fatal, not by coma, but merely by 
reason of the gradual failure of the strength of the cir- 
culation, which accompanies the repeated paroxysms of 
spasm, nearly as it accompanies violent spasms of the 
same description when produced in animals by the ac- 
tion of poisons, or by extensive injury of the spinal cord. 
This progress is, however, much more rapid in some 
cases than in others ; and there are many, particularly 
of the cases excited by cold, which are slow in their 
progress, and capable of being controlled by remedies. 

Hydrophobia is likewise produced by the action of a 
specific cause, and an interval, varying, in this case, from 
a few days to several months, likewise elapses between 



OF SPASMODIC DISEASES. 



715 



the time of its application and the commencement of the 
disease ; but in this case the cause is a peculiar animal 
poison, the conditions necessary to the generation of 
which are not yet ascertained, communicated only by 
inoculation, and which seems, like the poisons exciting 
the contagious exanthemata, to multiply itself in the 
blood during the latent period. The spasms are here 
first and chiefly in the muscles of the fauces, and are 
repeatedly excited or aggravated by external causes, by 
the contact of any fluid with the fauces, or even of cold 
air with the face ; but they generally extend over the 
body as the disease advances, and death takes place, as 
in Tetanus, not in the way of coma, but rather by syn- 
cope ; in consequence of the gradual depression of the 
heart's action that attends the violent spasms, perhaps 
in consequence partly of a sedative action of the conta- 
gious poison on the heart itself. 

Although a congestion of blood on the surface of the 
spinal cord has been described by some in cases of Te- 
tanus, and although an unusual vascularity in the mu- 
cous membrane of the pharynx and oesophagus is com- 
mon after Hydrophobia, yet these appearances are cer- 
tainly to no great extent ; it is probable that they may 
be rather effects than causes of the morbid actions ; and 
at all events, they do not afford, by comparison with 
other cases of inflammation of these parts, any explana- 
tion of the peculiar phenomena of these diseases, nor in- 
validate the conclusion, that they are both to be re- 
garded as strictly diseases of the Nervous System. 

The remedies which have seemed useful in Tetanus 
are very various, as may be understood from the condi- 
tion of the circulation attending it being various. In 
some acute cases the pulse is frequent and firm, and 



716 OUTLINES OF PATHOLOGY AXD PEACTICE. 



the spasms have been relieved by full bleeding; in 
others, of chronic form, a full allowance of wine has 
been taken during the disease with apparent advantage ; 
in all cases regular action on the bowels seems useful, 
and for this purpose very large doses of purgatives are 
required. In all cases, likewise, there is a clear indica- 
tion for the anti-spasmodics and anodynes; and very 
large doses of opiates, in particular, may be given with 
safety, and sometimes evidently with good eflPect. The 
advantage of combining mercury with the opium is more 
doubtful ; but in some cases the warm, and in others 
the cold affusion, and in some also the tobacco enema, 
have aided the anti-spasmodic effect. It has been said 
that similar means, particularly bleeding, and calomel 
and opium, have succeeded in some cases of Hydropho- 
bia ; but it seems very doubtful whether there had really 
been cases of spasm proceeding from that specific poison. 



Sect. IT. — Of Disordered Sensations. 

We have various instances of Sensations undergo- 
ing such change, both in kind and intensity, as to be- 
come decidedly morbid, for which we can assign no 
reason, either in the application of any known external 
agent to the Xervous System, or in any altered action 
of the Vascular System. There are cases of original 
defect of sensibility in the eye or ear, general or partial, 
i.e. either congenital Amaurosis or Deafness, or insen- 
sibility to certain colours or sounds, without any unna- 
tural appearance either in the exterior parts, or in the 
nerves of these org'ans; and there are cases likewise 
of such affections, or of Sujusiones of various kinds, 



OF DISORDERED SENSATIONS. 



717 



before the eyes, or Tinnitus Aurium, coming on in the 
progress of life, sometimes from a morbid state of the 
circulation in the brain, and admitting of relief, either 
from depleting, or from stimulating remedies, — some- 
times from irritations acting on distant parts, particu- 
larly on the Primse Vise, and admitting of relief from 
Emetics, purgatives, alterative, or soothing medicines ; 
and sometimes also without apparent cause, — without 
benefit from remedies applied, either to the state of 
the circulation in the head, or to the condition of any 
part by which the organs of sense may be thought to 
be sympathetically affected, — and without change of 
structure of the parts, or with such change only as may 
be regarded as the effect, not the cause, of the disease. 
These last cases are, therefore, not symptomatic of any 
other disease, but truly idiopathic disorders of Sensa- 
tion. 

A case of morbid sensation not uncommon in nervous 
constitutions, and often exciting unnecessary alarm, is 
the tickling feeling in the Larynx or Trachea, which ex- 
cites frequent dry cough, unattended with fever or other 
indication of disease of the lungs, or even of the bronchiee, 
and admitting of relief from the general treatment of 
strictly nervous diseases. 

Again, the Ana3sthesia or loss of common sensation 
in more or less of the surface of the body, although often 
manifestly the result of injury of some part of the Ner- 
vous System, and co-existing with other symptoms of 
palsy, occurs in some instances without such accompa- 
niments, and when no cause whatever appears for it on 
dissection. A morbid Sensation of Cold, or more fre- 
quently, in hysterical patients, of Heat externally, or in 



718 OUTLINES OF PATHOLOGY AND PRACTICE. 



internal parts, particularly the abdomen, is often, like- 
wise, a simply nervous affection. 

Much more frequently we meet with cases of Pain, 
referred distinctly to individual parts of the body, often 
very intense and very lasting, which the whole history 
of the cases shews to be strictly nervous ; ^. e, to be an 
alteration of the function of the nerves of the part, for 
which no adequate cause exists, either in any diseased 
structure, or in any diseased action of vessels. 

Such pains have the general name of Neuralgia, and 
the following appear the most important facts regarding 
them. 

1. They occur (chiefly in adults, and in persons whose 
health is otherwise disordered) in all parts of the body, 
but most frequently in the head and abdomen. Many 
headaches, and especially those which affect one side of 
the head, and recur at pretty regular intervals, and have 
the name of Hemicrania, or those remitting pains which 
affect only small spots on the cranium, and have the 
name of Clavus hystericus, are of this description ; so 
also is the severe pain of face termed Tic Douloureux. 
Some cases of Angina Pectoris appear from their his- 
tory to have no more permanent origin. Many cases of 
Gastrodynia, and of pains, even fixed and violent, re- 
ferred to different parts either of the abdomen or sides, 
or to the situation of the uterus and back, appear to be 
of this description ; and some cases of severe pain of 
the hip-joint, of the feet, or other parts of the lower 
limbs, are more correctly referred to this head than to 
Rheumatism. 

One form of these pains has been accurately described 
under the name of Spinal Irritation, and is distinguished 



OF DISORDERED SENSATIONS. 



719 



by pain and tenderness over tlie spinal processes of some 
of the vertebrae, connected with similar pains on corre- 
sponding parts of the thorax, and tenderness often on the 
slightest touch, implying that the pain on pressure is 
not the result of inflammation, but of morbid sensibility 
of the cutaneous nerves. 

2. They have been stated to follow evidently the 
course of certain nerves ; but this is neither uniform, 
nor characteristic, as distinguishing them from other 
diseases of nerves themselves. But they are chiefly 
characterized by the suddenness of their attack (which 
is repeated often at pretty regular intervals), and fre- 
quently of their abatement also ; by the total absence of 
heat, and swelling, and often of tenderness when they 
are external, and of febrile symptoms when they are in- 
ternal, even although their intensity be extreme ; by 
frequently appearing to be determined by sudden changes 
of weather ; by occurring chiefly in persons of nervous 
temperament, and in connexion frequently with other 
nervous afl'ections ; and by abating frequently under the 
use of anodynes, of a tonic regimen, cautiously adopted, 
and of remedies called Tonic (perhaps more properly 
specifics), rather than under antiphlogistic treatment. 

3. These pains, although hardly ever observed during 
violent inflammatory diseases, are by no means incom- 
patible, but on the contrary frequently combined, with 
such diseases in their subacute or chronic forms, and 
are apt to deceive us as to the violence or danger of 
such cases ; but their character may generally be de- 
tected by observing the correspondence, in more or fewer 
particulars, to the characters now stated. 

\ The Sensation of Vertigo, although often symptoma- 
tic, either of disordered circulation in the brain, or of 



720 OUTLINES OF PATHOLOGY AND PRACTICE. 

irritations affecting peculiarly tlae sensitive nerves of the 
stomacli or bowels, is sometimes independent of either 
of these causes, and can be referred only to a morbid 
action of some part of the Sensorium. 

The most extraordinary of all these cases of disor- 
dered Sensation is that of Spectral Illusions, i. e, of 
Sensations, often definite and complex, exactly resem- 
bling impressions on the external senses from the ex- 
ternal world, and equally independent of the will of him 
who feels them, but which result merely from internal 
causes. Such Sensations sometimes precede epilepsy, 
.sometimes occur in connection with apoplectic or paraly- 
tic attacks, often result from the use of narcotic medi- 
cines, or from repeated indulgence in strong liquors ; 
but in other cases, they cannot be traced to any such 
causes; and they must be regarded as indications, that the 
mental acts of Conception and Imagination are connected 
with changes in the nervous matter of the brain or me- 
dulla oblongata; which changes, when stronger and more 
enduring than usual, affect the mind in the same man- 
ner as the changes which result from external objects 
impressing the senses. 

In regard to all these disorders of Sensation, it may 
be observed, that although not necessarily dependent on 
obvious disorder of the circulation, or on irritations act- 
ing on the sentient extremities of nerves, or on any 
noxious matters taken into the circulation, they are al- 
ways easily aggravated by such causes ; and therefore, 
that evacuant and derivant remedies when the flow of 
blood to the head is in excess, gentle stimuli when it is 
deficient, laxatives, astringents, or anodynes, according 
to the state of the bowels, and a regulated diet, exclud- 



OF MENTAL DISORDERS- 



721 



ing all but the mildest stimuli, are proper in all such 
cases. When no such remedies appear to he demanded, 
or to be useful, we can have less expectation of giving 
relief to such cases ; but in some instances the cautious 
use of a Tonic regimen and remedies, with occasional aid 
from anodynes, appear to be decidedly beneficial, when no 
other cause can be assigned for such complaints than a 
morbid condition of those vital actions which are strictly 
confined to the Nervous System. The most striking 
examples of this kind, are the use of Quinine or of Ar- 
senic, in intermitting Hemicrania, and the use of pre- 
parations of Steel (particularly the Carbonate), in the 
Tic Douloureux, and in certain other forms of Neural- 
gia, particularly when aided by opiates internally, and 
by Belladonna or the Aconitin, externally. 



Sect, V. — Of Mental Disorders. 

III. The last class of diseases of the Nervous System 
is that of y esanise, or morbid changes of the purely men- 
tal powers or faculties ; which we can have no doubt 
depend on alteration of the state of the nervous matter 
in the brain; because we know that it furnishes the 
physical conditions necessary to the manifestation of all 
mental phenomena ; and this alteration is sometimes con- 
nected, in idiopathic Insanity as well as in symptomatic 
Delirium, with a disordered state of the circulation 
through the brain, or with organic disease there, or 
with the application of poisonous matters of the blood ; 
but in other cases, no one of these causes can be assigned 
for the morbid changes. 

The diseased states to which the mental powers are 



722 OUTLINES OF PATHOLOGY AND PRACTICE. 

liable, are most easily understood as consisting in, or 
depending on, alterations of tlie laws according to whicli 
tlie different thoughts succeed each other in the mind, 
and of the intensity and duration of the attention fixed 
on them, rather than of the nature of the mental acts 
themselves.* 

The great and obvious division of these diseased states 
is into the state of Amentia or Fatuity, and that of De- 
mentia or Insanity, both of which states admit of very 
considerable varieties. 

Both states are very frequently produced temporarily 
by inflammation, and by different febrile diseases, and 
more permanently by organic diseases, in which the 
brain is affected ; and both may be suspected to proceed 
in every case, from some alteration of the structure of 
the parts of the nervous system, with which the mind is 
specially connected ; but this alteration is certainly in 
many cases imperceptible by any means yet known for 
detecting such changes ; and some of the forms of both 
kinds of mental disease commence so suddenly, and 
abate so completely, that it is difficult to suppose any 
peculiarity of structure that may exist to be essentially 
connected with them, or to be on any other footing than 
a great predisponent cause of them. 

The state of Amentia is that in which impressions on 
the senses, although distinctly felt, and exciting certain 
mental acts, fail to suggest many of those thoughts 
which in men of sound minds would naturally, and ac- 
cording to the ordinary laws of association of thoughts, 
result from them. This obviously admits of a subdivi- 
sion, according as the deficiency lies in the simple sug- 



* See Physiology, p. 212 and 225. 



OF MENTAL DISOEDEES. 



723 



gestion of objects of sense, or of thouglits previously be- 
fore the mind in connection with each other, — or as it 
lies in the suggestion of tbe qualities and relations of 
things (whicb are perceived by what was described as 
tlie faculty of Abstraction), and of the abstract notions 
which were described, as either naturally attending dif- 
ferent acts of mind, or formed by our perception of the 
relations of things, — and which are the subjects of 
Judgment and Reasoning.* In the first case, there is 
merely loss of Memory ; in the second there is Idiocy ; 
and both admit of many varieties ; for in many persons 
some of the associations by which thoughts are laid 
together in the mind are retained, while others are lost ; 
and again, in many persons, some of the relations of 
things are distinctly perceived and remembered, while 
others are wholly overlooked. But in almost all cases 
we may be satisfied of the accuracy of the definition of 
Cullen, that the state of Amentia is that in which 
" rerum relation es vel non percipiuntur vel non reminis- 
cuntur." 

The state of permanent Idiocy is probably always the 
efi"ect of original malformation (often obvious on inspec- 
tion of the skull) or injury or alteration by disease of 
some part of the brain ; and when it takes place in the 
course of life (as, e. g. after long-continued chorea, or 
many fits of epilepsy) although often abating and recur- 
ring, is seldom permanently removed, and very often is 
a prelude to ultimate coma. The loss of Memory, though 
very often dependent on organic lesion, is often observed 
in old age, in persons convalescent from febrile dis- 
eases, &c. without visible change of structure ; in old 



* See Physiology, p. 331. 



724 OUTLINES OY PATHOLOGY AND PRACTICE. 



persons it often comes on in sudden fits, sometimes at- 
tended witli delirium, and repeatedly disappears again ; 
and there are some cases (cliieflj of the anomalous and 
slighter affections of the nervous system) where it oc- 
curs, even repeatedly, and disappears so suddenly and 
so completely, that we cannot suppose it to have been 
connected with disease of structure. 

The state of Somnambulism or Reverie, although one 
in which the mind often acts with great energy on certain 
objects of thought, is yet properly ranked under the head 
of Amentia, because some of the natural associations of 
thoughts are suspended, and certain of the relations of 
things are unperceived, and the conduct of the person af- 
fected thereby altered (sometimes without any hallucina- 
tion or delusion being perceptible) ; and when this morbid 
state of the mind ceases, little or no recollection is retain- 
ed of what passed during it. Short paroxysms of such a 
state are not uncommon, and have often been uncon- 
nected with any very serious disease, in persons of the 
nervous temperament, chiefly in women subject to the 
slighter nervous diseases ; and sometimes recur repeat- 
edly, the recollection of what happened during each 
being recovered in the next paroxysm. And in some 
cases this perverted condition of the mental powers has 
lasted so long, that knowledge previously obtained, or 
arts previously learnt, have been acquired again, during 
the suspension of the associating principles which had 
formerly suggested them ; and then the lost association 
has been suddenly restored, and the mind regained pos- 
session of all that had formerly been learnt.* 

* See Abercrombie on the Intellectual Powers, 3d edition, 
p. 303. 

4 



OF MENTAL DISORDERS. 



725 



The state of Dementia or Insanity is, perhaps, most 
miiformly characterized merely by the unusual energy 
or fervour with which certain acts of thought are per- 
formed, — especially acts of Conception and of Imagina- 
tion, and Emotions resulting from these ; which state 
of the mind is sometimes attended by a great accelera- 
tion, and sometimes by an equally distinct retardation, of 
the trains of thought. When those mental acts take place 
with morbid energy, and the attention is involunta- 
rily fixed on them with unnatural force, so as to ex- 
clude all other thoughts, which in the circumstances 
of the case would otherwise present themselves, the 
morbid energy of the conceptions or fancies, in the 
mind of the madman, most generally overpowers the 
checks, which, in the natural and healthy state, pre- 
vent our believing in the real and independent exist- 
ence of the images formed in our minds ;* and he then 
reposes belief in something which he has conceived or 
imagined, in like manner as all men do in the images 
presented during sleep; and this erroneous belief, or 
hallucination, " qua rerum relationes falsce percipiun- 
tur," shews itself in his language or actions, and indi- 
cates and characterizes his insanity. 

The erroneous belief being not the original and fun- 
damental change, but only the natural result of other 
previous changes in the state of the mind, it is obvious 
that we cannot draw a distinct line of demarcation be- 
tween Insanity and mere Eccentricity of character, only 
by trusting to the definition of Cullen ; and we can have 
no doubt that there are many cases, particularly of those 
kinds to which the names Moral and Instinctive In- 



* See Outlines of Physiology, p. 329. 
PART III. 3 A 



726 OUTLINES OF PATHOLOGY AND PRACTICE. 



sanity have been lately applied, in which insanity is 
indicated merely by morbid hurry and excitement, or 
by morbid earnestness and tenacity of thought, or by 
habitual gloomy ideas, or by open violations of decency 
or veracity, or by morbid propensities, such as that of 
drinking (when only occasionally recurring) — that of 
indulging in wholly irrational expenses — that of steal- 
ing — or of committing homicide, or even suicide, with- 
out any such motive, grounded on consideration of con- 
sequences of such actions, as can induce men of sound 
mind to commit them.* Still we may regard the defi- 
nition of Cullen as affording the simplest character by 
which the disease is to be recognised in the great ma- 
jority of cases « 

This morbid state of the train of thought in the mind 
obviously admits of very considerable variety, without 
deviation from these essential characteristics. 

In some cases, all, or almost all, the images formed in 
the mind are equally the subjects of this erroneous be- 
lief ; so that the patient, although his mind will gene- 
rally act for a short time in the natural way on any new 
object presented to his senses, and arresting his atten- 
tion, yet, as often as he returns to those trains of thought, 
of which conception and imagination form a large part, 
relapses into the varied hallucinations that spring from 
the faith erroneously reposed in the images which these 
faculties present to him. This is the state of the mind 
in what is properly called Delirium^ so common in febrile 
diseases, and occurring occasionally in the course of many 
cases of more permanent insanity. 

In other cases, it is only in regard to certain objects 

* See Pricliarcl"'s Treatise on Insanity. 



OF MENTAL DISORDERS. 



727 



of thought that the mind acts with morbid fervour, and 
therefore forms false judgments ; and in regard to others, 
its operations are nearly natural. This is generally the 
case when there is no febrile action in the system, and 
the term Mania is then more correctly applied. In some 
such cases, the subjects of false judgment are very li- 
mited and unvaried for a great length of time ; and such 
cases (called Melancholia by Cullen), are usually termed 
Monomania. 

Again, there are many cases of mental derangement, 
where the whole train of thought is much more rapid 
than natural ; and some where it is so rapid that the 
control of the will over it is evidently suspended ; and 
the language of the patient so rambling and incoherent 
as to convey no definite meaning. This is the state to 
which Pinel, and other French authors, restrict the word 
Demence. When there is such rapidity of thought, the 
emotions attending the insanity are generally of the ex- 
citing class, either joy or anger. 

On the other hand, there are many cases in which the 
train of thought is much slower than natural, or the 
succession of acts of thought almost suspended, the mind 
dwelling almost exclusively on particular images. In 
such cases, these images are usually attended by painful 
or depressing emotions, and the term Melancholy is that 
generally applied. 

In many cases, along with, and consequent on, the 
delusions and emotions attending them, there is, at least 
occasionally, a propensity to violent and outrageous acts ; 
and, in some cases (as may be judged from what has 
been stated above), this propensity shews itself so sud- 
denly, and with so little apparent cause in the previous 
language or conduct of the maniac, as to lead to the sup- 



728 OUTLINES OF PATHOLOGY AND PRACTICE. 

position that it is the sole disorder of the mind ; but it 
is a matter of great difficulty and nicety to judge, in 
what cases we may hold such a propensity to be a suffi- 
cient indication of insanity, although it cannot be shewn 
to coexist with any mental delusion. 

Again, there is a distinction, easily observed in many 
cases, and of considerable importance, between those 
forms of insanity, where the delusions rest on erroneous 
conceptions of what has actually been before the senses, 
and those where they rest on morbid acts of imagination 
only, whereby persons or things are invested with fancied 
qualities, which are not supposed to have been actually 
under the observation of the maniac, but of the existence 
of which he nevertheless entertains a thorough convic- 
tion. This distinction is expressed by Dr Arnold by 
the terms Ideal and Notional Insanity.* The delusions 
in a case of delirium tremens from drinking, which are 
generally founded on morbid sensations, and on the re- 
collections of these, are an example of the first kind ; 
and the common hallucination of a combination or con- 
spiracy formed to injure the affected person (who gene- 
rally supposes, in such cases, not that he has seen or 
heard proofs of what he alleges, but that he has divined 
the thoughts of his enemies), is of the last kind, which 
is probably the more inveterate malady of the two. 

The following facts are well ascertained by experi- 
ence, in regard to the circumstances in which the diseased 
actions of the nervous system, on which these lesions of 
the mental faculties depend (but which are known to us 
only by their effects), are chiefly observed. 

1. Abstracting from the case of the delirium of fever. 



* Observations on Insanity, vol. i. p. 72. 



OF MENTAL DISORDERS. 



729 



there is only a small portion of the human race who are 
susceptible of this kind of disease. 

2. In a very large proportion, probably a majority, 
of those who are affected in these ways, a predisposition 
from hereditary constitution may be traced. 

3. In a large proportion also, some of the organic 
diseases within the cranium, formerly mentioned (p. 682), 
are found on dissection, with or without serous efiPusion, 
and frequently there are marks either there or in other 
parts of the body, of scrofulous disease. Where there 
has been no organic disease, something unusual in the 
form or texture of the bones of the head has often been 
remarked. 

4. In those predisposed by known or unknown causes, 
the disease shews itself more frequently between the age 
of twenty-five and forty, than any other time of life ; 
and the earlier it does so, there is the more chance of at 
least temporary recovery. 

5. In those predisposed, mania may be excited by al- 
most any cause adequate to excite any kind of disease ; 
probably the most frequent exciting causes are, intem- 
perance in the use of strong liquor, or in venereal indul- 
gences, the irritation of mercury, long continued exter- 
nal heat, injuries on the head, the suppression of usual 
evacuations, and mental emotion. In many cases, the 
symptoms attending a violent fit of Mania, excited by 
any of these, as well as the nature of the causes, the 
other diseases with which it may be combined, the ju- 
vantia and Isedentia, and the effusions in the brain fre- 
quently found after such a fit has been fatal, clearly in- 
dicate that an increased determination of blood, and 
frequently even an inflammatory action, has preceded 
and accompanied the attack; but in every such case, a 



730 OUTLINES or PATHOLOGY AND PRACTICE. 



peculiar predisposition must liave existed to give this 
character to tlie effect of such morbid determination ; 
and in many of the cases, where the predisposition is 
strong, little or no excitement by any of those external 
circumstances can be perceived. 

In some cases, organic diseases of the heart give 
a manifest disposition to Insanity, as they have been 
already stated to give the tendency to Apoplexy or Epi- 
lepsy; and in a greater number, disordered states of 
the stomach and bowels, probably by reason of the pe- 
culiarly oppressive sensations attending them, appear to 
excite the disease. 

The cases of insanity which present the best pros- 
pect of a perfect recovery of the mental powers, are 
those in which the action of a powerful exciting cause 
is the most manifest, and previous disposition least ob- 
vious ; but these are also the cases which bear the 
closest analogy to inflammation, and in which there is 
perhaps the greatest risk of the maniacal excitement, if 
not moderated by remedies, quickly subsiding into fatal 
coma. Such are many of the cases of insanity imme- 
diately succeeding delivery. 

The Delirium Tremens from drinking (but which al- 
most invariably commences after the excitement from 
the strong liquor is over) may be said to differ from 
other cases of insanity, in shewing throughout its course 
the action on the brain of a substance which affects the 
constitutions of the patients, on the footing of a poison, 
but not of a narcotic poison. The mental hallucina- 
tions are founded in a great measure on what may 
strictly be called spectral illusions, and are attended 
uniformly with tremors resembling but exceeding those 
of typhoid fever. The effect of this poison to pro- 



OF MENTAL DISOEDEKS. 



731 



duce this form of disease is manifestly determmed by 
previous predisposition, the effect being seen only in 
a very small proportion of those to whom the cause 
is applied. And the specific action of the poison on 
the brain and nerves appears manifestly to be aggra- 
vated and maintained, sometimes by a morbidly dimi- 
nished, and at other times by an increased, action of 
vessels, — as indicated both by the symptoms accom- 
panying the mental derangement, and also' by the ju- 
vantia and Isedentia ; the specific effect of opium, in 
controlling the characteristic symptoms of the disease 
being sometimes certainly aided by antiphlogistic, and 
at other times by stimulant remedies. 

The peculiar agency of a cause affecting the nervous 
system in this disease after the manner of a poison, is 
shewn by the mode of fatal termination of the disease, 
which is hardly ever preceded by coma, but takes place 
almost instantaneously, or in the way of syncope. 

In almost all other cases of Mania, the immediate 
danger of death, in so far as it is connected with the men- 
tal disease, may be said to depend on the gradual ac- 
cession of coma j and the fatal result is accordingly 
very generally preceded by a combination of other of 
the cerebral diseases. Epilepsy, Phrenitis or Hydro- 
cephalus, &c. and very often Fatuity ; — which combi- - 
nations seems to be owing, sometimes to extension of 
organic disease in the brain, and sometimes to acces- 
sion of more acute disease there. 

The remarkably partial affection of the mental powers, 
in many cases of Mania and Melancholia, and the limi- 
tation of the morbid condition of the mind, in many 
cases, to its exercise on particular objects of thought, 
may be thought to favour the supposition of the ap- 



732 OUTLINES OF PATHOLOGY AND PRACTICE. 



propriation of individual parts of the brain, either to 
particular acts of mind, or to acts of the mind on par- . 
ticular subjects ; but it does not appear, on examination 
of this subject, either that the allocation of the different 
operations of the mind, in the different parts of the 
brain, proposed by Gall and Spurzheim and their fol- 
lowers, is confirmed by observation of the portions found 
to be diseased in these cases of partial insanity ; or that 
the forms of the partial insanity itself correspond to 
their divisions and arrangement of the mental acts. 

The state of Amentia is hardly ever a direct object of 
medical practice, but is sometimes seen to diminish and 
disappear very remarkably, when the cause from which 
it proceeds is one which admits of a cure, spontaneous 
or artificial, as in the convalescence from fever and from 
apoplexy, or other serious diseases of the brain. Even 
the Amentia of old people, ^ — often connected with occa- 
sional fits of delirium, and admitting of frequent abate- 
ment before it becomes permanently fixed, when at- 
tended with febrile excitement or symptoms of Plethora 
Capitis, may be relieved by moderate evacuations, an- 
timonials, or other sedatives, and especially by a com- 
bination or alternation of such remedies with opiates. 

The singular form of Amentia, to which the term Som- 
nambulism or E-everie is applied, like other anomalous 
conditions of the Nervous System, sometimes admits of 
great relief from medical treatment, when it is distinctly 
ascertained to be connected with any tangible bodily ail- 
ment, — with excitement of the circulation and determi- 
nations to the head, which may be moderated by depletion, 
— with irritation of the intestines, or retention and accu- 
mulation of feeces, which may be removed by thoroughly 

2 



OF MENTAL DISORDERS. 



733 



evacuating, and, at the same time, soothing the bowels 
or with retention of the menses, which may be remedied 
by a tonic regimen and emmenagogues. But when no 
indications for such active treatment present themselves, 
it is to be remembered that complaints of that kind may 
last long, and cause much anxiety, and resist much 
treatment, and afterwards spontaneously and even sud- 
denly abate, provided that the digestion and assimila- 
tion of food continue in a tolerably healthy state. 

In cases of Dementia, or of the different forms of 
Insanity, the general objects of medical treatment may 
be said to be these : — 

1. In those known to be predisposed, to avert, as far 
as possible, all exciting causes, and keep the suspected 
persons in a state the least likely to pass into the dis- 
ease. 

2. To oppose the diseased action by medical treat- 
ment, so far as that is likely to be of service. 

3. To adopt such a regimen, and such moral treat- 
ment, as is found to conduce to the spontaneous abate- 
ment of the paroxysms of the disease. 

1. The first object is to be accomplished chiefly by 
much bodily exercise, and such a mode of life as shall 
occupy and interest the mind, without straining the men- 
tal powers, or exciting any violent or engrossing emo- 
tions ; with strict temperance as to strong liquors, mo- 
deration as to animal food, and regularity as to the 
taking of food, and the enjoyment of sleep. 

2. In those cases of insanity which are of recent oc- 
currence, and attended with frequency and fulness of 
pulse, or with symptoms of determination to the head, 
decided advantage may be derived from bleeding, purg- 
ing, cold applications to the head, and sometimes from 

PART III. 3 b 



734 OUTLINES or pathology and pkactice. 



nauseating doses of antimony ; and, after the system 
has been so far lowered by these means, opiates may 
in some persons be given in full and repeated doses with 
very good effect; but when we have reason to suspect 
organic disease, the opiates cannot be expected to do 
good ; and in some constitutions they have always un- 
pleasant effects. 

The case of Delirium Tremens differs from other 
forms of Insanity, not only in the peculiarity of the 
symptoms, but in the nature of the exciting cause, viz. 
the action on the Xervous System of a specific stimu- 
lus, which has been, in general, suddenly withdrawn, 
before the disease distinctly shews itself ; and in that 
case, the soothing effects of opium, in procuring sleep, 
and total abatement of the symptoms^ have been often 
strikingly seen. The use of this remedy should be pre- 
ceded and accompanied by purgatives, and either by 
small bleeding, and nauseating medicines, — or by sti- 
mulants, according to the state of the circulation ; the 
efficacy of depletion in some cases, and of stimulation 
in others, as auxiliaries to the opium, is clearly ascer- 
tained, and often exemplified. 

In other cases of Insanity, and particularly when it 
is observed that the patient enjoys pretty natural sleep, 
without restoration of the natural state of his mind, ex- 
perience has shewn that persistence in the use of de- 
pleting remedies, and even of antiphlogistic regimen, 
may only weaken and injure his bodily health and 
retard rather than accelerate that spontaneous abate- 
ment of the disease which may generally be expected, 
although at very irregular periods from its accession. 

3. The moral treatment of patients during the pa- 
roxysms of Insanity, consists essentially in the follow- 



OF MENTAL DISORDERS. 



735 



ing particulars '—firsts Preventing injury to themselves, 
or to others, by confinement, or by such means of re- 
straint as are consistent with humanity, and are least 
likely to excite unavailing and exhausting efforts of the 
patient to escape from them; secondly^ Removing all 
exciting causes which may aggravate or renew the mor- 
bid trains of thought, and accompanying violent or ab- 
sorbing emotions ; and, thirdly^ Taking advantage of 
that law of the mind, by which different acts or feel- 
ings are virtually rendered incompatible with one an- 
other, and placing the patient in circumstances which 
tend as much as possible to divert his attention from 
those thoughts, of which the morbid fancies or delu- 
sions are a constituent part, and to fix it on other objects, 
on which the mind can still act in the natural way. 

These principles enable us to perceive the importance 
of the seclusion and separation of insane persons from 
former friends and accustomed scenes ; of having them 
watched by careful and experienced attendants ; of their 
dangerous propensities being checked, particularly dur- 
ing the occasional paroxysms of general, or what is cal- 
led maniacal, excitement, without any appearance of 
violence or anger; of various occupations and amuse- 
ments being assiduously provided for them, particularly 
such as to induce them to muscular exertion ; of their 
diet being such as fully satisfies their appetites (often 
strong in the chronic state of the disease), without op- 
pressing the stomach ; even of such society being pro- 
vided for them, as a well regulated Lunatic Asylum 
presents, with the precautions which are there easily 
taken, against excitement or intemperance. 

Under such management, the exasperation of insanity 
to violent maniacal paroxysms, is often prevented, or 



v.. 

\ ■ 



736 OUTLINES OF PATHOLOGY AND PRACTICE. 

greatly mitigated ; when the disease is complicated with 
epilepsy, or other obvious disease, and probably con- 
nected with organic lesion, it usually gradually subsides 
into Fatuity ; in other cases, after several variations of 
character, it often gradually disappears, at least for a 
time ; and the most important practical caution, in re- 
gard to such cases is, that the patients should always 
be kept in seclusion for a considerable time after they 
have ceased to betray every symptom of insanity, in 
order that the diseased actions (always easily repro- 
duced) should have full time to subside completely, be- 
fore the re-application of any of those causes of mental 
excitement, which are necessarily implied in the re- 
moval of restraints, and the return to those scenes and 
occupations in which the disease had originated. 



THE END. 



PRINTED BV xNElLL AND COMFANV. KDINBDRGH. 



^' E 9 0 6^ 



